Six Keys to Safer Hospitals

Six Keys to Safer Hospitals

Six Keys to Safer Hospitals
A set of simple precautions could prevent 100,000 needless deaths every year.

By Donald M. Berwick, M.D.
Newsweek, December 12, 2005

Sometime soon, I will need a new right knee. If all goes well, it will be quite a relief. An artificial joint can be a modern miracle, the alternative to decades of pain and hobbling. Here's the problem. Instead of helping me, health care might kill me. In 1999, the Institute of Medicine shocked the nation with an authoritative report on hospital errors. The report concluded that up to 98,000 Americans each year die in hospitals, not from the diseases that brought them there but from injuries caused by their medical care: preventable bleeding or infections, a medication mix-up, a respirator tube put in the wrong way and a lot more. I have climbed Mount Rainier five times. Each time I made that tough trek, my risk of dying was about 100 times smaller than the risk I will face on the operating table.

Even if the surgery doesn't kill me, it may still cause needless harm. The reason I need a new knee is that I have osteoarthritis?the result of a botched and unnecessary knee operation 30 years ago, when I was a naive and trusting medical student. What could go wrong this time? My postoperative pain may not be adequately controlled. I may receive the wrong dose of blood thinner, causing bleeding in my stomach. Someone may overlook the little patch of pneumonia on my routine postoperative chest X-ray, causing me to remain on a respirator in the intensive-care unit for several days. Or the hospital may fail to take steps that could prevent the pneumonia in the first place.

Fortunately, hospitals are beginning to realize that it doesn't have to be this way. On Dec. 14, 2004, the Institute for Healthcare Improvement, a nonprofit organization headquartered in Cambridge, Mass., launched the 100,000 Lives Campaign, a broad national effort to achieve the most urgent reforms. Mainstream leadership groups like the American Medical Association, the American Nurses Association and the Joint Commission on Accreditation of Healthcare Organizations immediately signed on to the campaign. Several federal agencies?including the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Veterans Health Administration and the Agency for Healthcare Research and Quality?pledged support as well.

We have identified six basic measures that could save as many as 100,000 lives a year if even 2,000 hospitals adopted them. It's surprising to learn that these standards aren't already the norm?but the norms may finally be changing. Nearly 3,000 American hospitals have enrolled in our 100,000 Lives Campaign over the past year, and more than half are reporting their monthly death rates so that we (and they) can track progress. That takes courage in a world where hospitals, fearing blame and lawsuits, too often feel the need to hide their mistakes.

What exactly will it take to improve the quality of care? Here are the prescriptions that we and our partners are advancing. You don't have to be a doctor to understand them.

1 PREVENT RESPIRATOR PNEUMONIA
VAPs, or ventilator-associated pneumonias, are often deadly lung infections that people on respirators can get (after surgery, for example). A few simple maneuvers, like elevating the head of the hospital bed and frequently cleaning the patient's mouth, can eliminate them. Dominican Hospital in Santa Cruz, Calif., just celebrated one full year without a single VAP?a result most doctors would have thought impossible.

2 PREVENT IV-CATHETER INFECTIONS
Central-line infections occur when bacteria contaminate catheters that deliver food and medicine intravenously. Dr. Peter Pronovost of Johns Hopkins University recently reported that 70 hospitals in Michigan, California, Iowa and Indiana cut their central-line infections by half, saving an estimated $165 million from complications to boot. How did they do it? They made it easy for doctors and nurses to wash their hands between patients, adopted simple procedures for changing the bandages around the catheters and made absolutely sure that no catheter remained in a vein even one hour longer than needed.

3 STOP SURGICAL-SITE INFECTIONS
Surgical-site infections are a major cause of complications and deaths after operations. Last year Mercy Health Center in Oklahoma City operated on 1,200 consecutive patients without a single wound infection?by adopting a series of simple preventive measures. These include giving the right antibiotics at the right time during surgery, enforcing strict hand-washing and avoiding shaving the surgery site before the operation (clipping hair avoids nicking the skin and is safer).

4 RESPOND RAPIDLY TO EARLY-WARNING SIGNALS
A nurse or visitor is often the first person to notice that a patient is in trouble. By setting up special rapid-response teams, hospitals can ensure that these critical warnings are never missed or ignored. Busy physicians may resent the false alarms, but lives are saved when hospitals take nurses' concerns seriously and respond within minutes. Australian researchers have found that rapid-response teams may be able to cut hospital death rates by 20 percent or more. The University of Pittsburgh Medical Center is testing an even more innovative way to use rapid-response teams. The staff trains patients' visiting family members to call for assistance whenever they sense trouble. The new protocol, dubbed Condition H (for "Help"), has already saved lives.

5 MAKE HEART-ATTACK CARE ABSOLUTELY RELIABLE
The scientifically correct treatments for heart attacks could save far more lives if we used them reliably. The 100,000 Lives Campaign simply asks hospitals to ensure that every patient gets every medication and treatment recommended by the American College of Cardiology and other expert bodies. These measures include aspirin and a beta blocker on arrival and a stent or clot buster promptly after admission. McLeod Regional Medical Center in Florence, S.C., has cut the death rate among its heart-attack patients from 10 per-cent (the U.S. average) to about 4 percent. All the hospital had to do was ensure 100 percent reliability.

6 STOP MEDICATION ERRORS
Medication errors kill tens of thousands of patients a year, yet many are easily prevented. One secret is to "reconcile" medications whenever patients move from one care setting to another?from hospital to home, or even from one place to another within a hospital. The reconciliation protocol assigns a doctor or nurse at every step to check and recheck: are the medicines the patient gets after the transfer exactly the ones planned before the transfer? If not, the mistake gets corrected right away.

How much difference are we making through these efforts? We don't yet know whether the campaign will save 100,000 lives in its first year. Talk is cheap; changing the culture of a hospital is hard. But I've got a stake in it. When I close my eyes on the operating table so that a surgical team can implant my shiny new pain-free titanium knee, I know exactly what I want: safe, effective care, without a single complication.

BERWICK is president and CEO of the Institute for Healthcare Improvement (ihi.org) and clinical professor of pediatrics and health-care policy at Harvard Medical School. For more information, visit health.harvard.edu/NEWSWEEK.

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