New Center Takes Proactive Approach to Patient Safety
System Patient Safety Officer Mitesh Rao, MD, MHS, is the mastermind of a new proactive approach to patient safety, which uses four separate scientific disciplines to redesign systems and devices to prevent patient harm.
March 2017
In a departure from traditional, reactive patient safety methods, Stanford Health Care has added a proactive arm to its program. The new Center for Advancing Patient Safety, which launched last September, brings together a team of patient safety scientists to uncover vulnerabilities in the system, and redesign them to prevent adverse events from occurring. The Center complements the work of the traditional patient safety team, which responds to adverse events after they occur and educates staff to prevent further harm.
“Having a proactive program is a very novel approach to safety science,” said Mitesh Rao, MD, MHS, director of the Center and system patient safety officer. “This approach is about taking parts of the health system and looking at how we can make them more resilient. We call it Safer System Redesign.”
Through the Center for Advancing Patient Safety (CAPS), Stanford has built a scientific approach to improving safety, bringing on four separate scientific disciplines to redesign and improve systems, said Rao. Currently, the CAPS team includes a human factors and ergonomics engineer and a nurse simulation specialist. When fully assembled, the team will include a design thinker and a systems engineer.
The CAPS team culls through patient data to identify areas where adverse events have occurred, and then analyzes current-state processes to tease out vulnerabilities and system failures. In an institution as large and complex as Stanford, the systems in place are not always easy to navigate or user friendly, said Rao. As a result, clinical and support staff are often forced to create workarounds in order to get their jobs done.
“Nurses and physicians want to provide the best level of care, which often means succeeding in spite of the system, not because the system supports them,” said Rao. “Our goal is to make a system that supports safer behaviors, where it is easier to do the right thing and harder to accidentally cause patient harm.”
The Center for Advancing Patient Safety is supported by Patient Safety Champions—physician and nurse dyads from surgery, emergency medicine, ICU, critical care and general medicine—who provide clinical insight to the team of patient safety scientists. These dyads look for opportunities for improvement within their own areas and identify and lead their own work.
To date, the Center for Advancing Patient Safety has been working on two primary cases with hospital-wide affect—blood transfusions and lumbar drains.
Case 1: Blood transfusions
The CAPS team identified discrepancies throughout the hospital in how blood transfusions occur. The team mapped out the entire process from how blood is ordered to how it’s obtained from the lab and how it’s administered to the patient. They also ran a patient simulation, following and observing an order as it passed through the organization to the patient. From that analysis, they created a catalog of opportunities for improvement in Epic, in nursing and physician practices and in transfusion.
“We would have never known the need to fix all these disparate pieces if the team hadn’t gone through and broken down the entire practice to understand it,” said Rao.
Case 2: Lumbar drains
The team also discovered a pattern of adverse events in lumbar drains and external ventricular drains (EVD), many of which were traced back to design flaws within the device. There were a number of elements that made the devices we use unsafe, said Rao, such as the ability to inject the wrong substance or make the wrong connection. The team looked at where lumbar drains and EVDs are used, and found multiple devices and set-ups in place throughout the hospital. CAPS is now standardizing the devices used, and working with the manufacturer to redesign a better device, one that encourages safety, rather than one that allows for unsafe operations.
“This project used design thinking and human factors engineering, and benefitted from the engagement and feedback of stakeholders, the neurosurgeons and anesthesiologists who are providing deep insight on how these devices are supposed to be used and championing the change,” said Rao. “There’s an opportunity to standardize the devices used, and make them safer at the same time.”
Safety Partners
Most of the improvement work being conducted by the Center for Advancing Patient Safety was first identified by clinicians in the field and brought to the attention of the patient safety team.
“We have an open door policy,” said Rao. “We rely on physicians and nurses to let us know when they identify opportunities for improvement.”
To make a safety improvement suggestion, contact the Center for Advancing Patient Safety at caps-consult@stanfordhealthcare.org.