Embargoed Until:
April 7, 2009
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Researchers Led By Leading Patient-Safety Analyst Working To Form Public-Private Alliance To Improve Patient Safety

Pronovost And Colleagues Say Major Stakeholders Have Agreed To Participate In Group Modeled On Aviation Industry Safety Alliance

Bethesda, MD -- A public-private alliance known as the Commercial Aviation Safety Team (CAST) has greatly improved aviation safety. A similar alliance among health care stakeholders could reduce medication and device errors and wrong-site surgeries, renowned patient safety expert Peter Pronovost and coauthors say in an article published today on the Health Affairs Web site. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w479

Pronovost and his colleagues are working to establish a health care counterpart to CAST, which they call the Public Private Partnership to Promote Patient Safety, or P5S. Under a planning grant from the Robert Wood Johnson Foundation, they are refining plans for the governance, processes, and finances of P5S, for presentation to stakeholders this summer. (Among those involved in this effort has been Harvard Medical School professor David Blumenthal, the incoming National Coordinator for Health Information Technology.) Thus far, all of the major stakeholders, including the Agency for Healthcare Research and Quality (AHRQ), the Food and Drug Administration (FDA), the Joint Commission, the ECRI Institute, and more than 15 large health systems, have agreed to participate.

The authors of the Health Affairs article, including AHRQ director Carolyn Clancy, say that AHRQ should be the driving force in creating P5S. The agency already oversees the Patient Safety Organizations (PSOs) created to receive medical-error reports under the Patient Safety and Quality Improvement Act passed by Congress in 2005.

Contrasting Safety Records: Success In Aviation, Futility In Health Care

CAST brings together the entire aviation industry, including major manufacturers, airlines, and labor organizations; government agencies such as the Federal Aviation Administration (FAA); and international organizations such as the Flight Safety Foundation. Since its founding in 1997, CAST has helped the aviation industry improve an already admirable record of safety. Between 1994 and 2004, the average rate of fatal accidents decreased from 0.05 to 0.02 per 100,000 departures.

In the health care system, by contrast, preventable patient deaths and injuries continue unabated, despite hospital root-cause analyses and interventions to mitigate risks, and despite the Institute of Medicine’s call in 2000 for a 50 percent reduction in preventable patient harm within five years.

"Because it involves all the major stakeholders, CAST provides the resources to do in-depth investigations of accidents and near-misses, to develop and implement strong interventions that can prevent the problem from recurring, and to evaluate the effectiveness of those interventions. In contrast, the individual institutions that typically investigate medical errors often lack resources to conduct frequent and intensive investigations, and they lack the ability to implement strong interventions such as redesigning widely used medical equipment in ways that would make error impossible," said Pronovost, a professor in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University in Baltimore.

For example, errors are common when physicians use hospital defibrillators to shock the hearts of cardiac arrest victims back into normal rhythms. Hospitals attempt to reeducate their staff, but this intervention often fails because it relies on fallible human memory and attention. "A more efficient and effective approach would involve collaborating with industry to redesign defibrillators (for example, with automated default settings)," but this would require "a coordinated effort among manufacturers, clinicians, human-factors engineers, and regulators," Pronovost and his coauthors write. P5S would provide a forum for this collaboration that does not currently exist.
           
Obstacles To Establishing P5S

Pronovost and coauthors discuss several potential obstacles to establishing a health care counterpart to CAST. First, while the aviation industry features well-defined settings and teams, the health care industry features "an immeasurable number of clinical areas, therapies, technologies, protocols, and provider types, which makes indentifying, measuring, and prioritizing hazards difficult." The researchers suggest that P5S should begin with a narrow focus on poorly designed equipment and other technology problems before moving on to more complex safety issues such as culture, diagnostic errors, and cognitive errors in surgery.

In addition, commitment to safety and knowledge of safety issues varies much more among health care stakeholders than it does among aviation stakeholders. Moreover, aviation stakeholders have agreed not to compete on safety issues, but many in health care believe that providers should in fact compete on safety. "Consequently, the readiness of health care organizations to partner in P5S is uncertain," Pronovost and coauthors acknowledge.

Finally, aviation comprises large organizations that are able to provide funding and staff support to CAST. The smaller organizations that dominate the health care industry might find these burdens harder to bear. Pronovost and his colleagues suggest that "the federal government would be the best candidate to support P5S." Currently, government agencies invest only a penny in patient safety for every dollar they invest in basic and clinical research, the authors point out.

After the embargo lifts, you can read the paper by Pronovost and coauthors at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w479


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HEALTH AFFAIRS:

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.

 

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