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Doctor Leads Quest for Safer Ways to Care for Patients
By CLAUDIA DREIFUS

Q. WHAT GOT YOU STARTED ON YOUR CRUSADE FOR HOSPITAL SAFETY?

A. My father died at age 50 of cancer. He had lymphoma. But he was diagnosed with leukemia. When I was a first-year medical student here at Johns Hopkins, I took him to one of our experts for a second opinion. The specialist said, “If you would have come earlier, you would have been eligible for a bone marrow transplant, but the cancer is too advanced now.” The word “error” was never spoken. But it was crystal clear. I was devastated. I was angry at the clinicians and myself. I kept thinking, “Medicine has to do better than this.”

A few years later, when I was a physician and after I’d done an additional Ph.D. on hospital safety, I met Sorrel King, whose 18-month-old daughter, Josie, had died at Hopkins from infection and dehydration after a catheter insertion.

The mother and the nurses had recognized that the little girl was in trouble. But some of the doctors charged with her care wouldn’t listen. So you had a child die of dehydration, a third world disease, at one of the best hospitals in the world. Many people here were quite anguished about it. And the soul-searching that followed made it possible for me to do new safety research and push for changes.

Q. What exactly was wrong here?

A. As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture. When confrontations occurred, the problem was rarely framed in terms of what was best for the patient. It was: “I’m right. I’m more senior than you. Don’t tell me what to do.” With the thing that Josie King died from — an infection after a catheter insertion, our rates were sky high: about 11 per 1,000, which, at the time, put us in the worst 10 percent in the country.

Catheters are inserted into the veins near the heart before major surgery, in the I.C.U., for chemotherapy and for dialysis. The C.D.C. estimates that 31,000 people a year die from bloodstream infections contracted at hospitals this way. So I thought, “This can be stopped. Hospital infections aren’t like a disease there’s no cure for.” I thought, “Let’s try a checklist that standardizes what clinicians do before catheterization.” It seemed to me that if you looked for the most important safety measures and found some way to make them routine, it could change the picture.The checklist we developed was simple: wash your hands, clean your skin with chlorhexidine, try to avoid placing catheters in the groin, if you can, cover the patient and yourself while inserting the catheter, keep a sterile field, and ask yourself every day if the benefits of catheterization exceed the risks.

Q. WASH YOUR HANDS? DON’T DOCTORS AUTOMATICALLY DO THAT?

A. National estimates are that we wash our hands 30 to 40 percent of the time. Hospitals working on improving their safety records are up to 70 percent. Still, that means that 30 percent of the time, people are not doing it.

At Hopkins, we tested the checklist idea in the surgical intensive care unit. It helped, though you still needed to do more to lower the infection rate. You needed to make sure that supplies — disinfectant, drapery, catheters — were near and handy. We observed that these items were stored in eight different places within the hospital, and that was why, in emergencies, people often skipped steps. So we gathered all the necessary materials and placed them together on an accessible cart. We assigned someone to be in charge of the cart and to always make sure it was stocked. We also instituted independent safeguards to make certain that the checklist was followed.

We said: “Doctors, we know you’re busy and sometimes forget to wash your hands. So nurses, you are to make sure the doctors do it. And if they don’t, you are empowered to stop takeoff on a procedure.”

Q. HOW DID THAT FLY?

A. You would have thought I started World War III! The nurses said it wasn’t their job to monitor doctors; the doctors said no nurse was going to stop takeoff. I said: “Doctors, we know we’re not perfect, and we can forget important safety measures. And nurses, how could you permit a doctor to start if they haven’t washed their hands?” I told the nurses they could page me day or night, and I’d support them. Well, in four years’ time, we’ve gotten infection rates down to almost zero in the I.C.U.

We then took this to 100 intensive care units at 70 hospitals in Michigan. We measured their infection rates, implemented the checklist, worked to get a more cooperative culture so that nurses could speak up. And again, we got it down to a near zero. We’ve been encouraging hospitals around the country to set up similar checklist systems.

Q. IN YOUR BOOK, YOU MAINTAIN THAT HOSPITALS CAN REDUCE THEIR ERROR RATES BY EMPOWERING THEIR NURSES. WHY?

A. Because in every hospital in America, patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant. Yet, a nurse or a family member may be with a patient for 12 hours in a day, while a doctor might only pop in for five minutes.

When I began working on this, I looked at the liability claims of events that could have killed a patient or that did, at several hospitals — including Hopkins. I asked, “In how many of these sentinel events did someone know something was wrong and didn’t speak up, or spoke up and wasn’t heard?”

Even I, a doctor, I’ve experienced this. Once, during a surgery, I was administering anesthesia and I could see the patient was developing the classic signs of a life threatening allergic reaction. I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.” All communication broke down. I couldn’t let the patient die because the surgeon and I weren’t connecting.

So I asked the scrub nurse to phone the dean of the medical school, who I knew would back me up. As she was about to call, the surgeon cursed me and finally pulled off the latex gloves.

Q. WHAT CAN CONSUMERS DO TO PROTECT THEMSELVES AGAINST HOSPITAL ERRORS?

A. I’d say that a patient should ask, “What is the hospital’s infection rate?” And if that number is high or the hospital says they don’t know it, you should run. In any case, you should also ask if they use a checklist system.

Once you’re an in-patient, ask: “Do I really need this catheter? Am I getting enough benefit to exceed the risk?” With anyone who touches you, ask, “Did you wash your hands?” It sounds silly. But you have to be your own advocate.

Dr. Peter J. Pronovost, 45, is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, which means he leads that institution’s quest for safer ways to care for its patients. He also travels the country, advising hospitals on innovative safety measures. The Hudson Street Press has just released his book, “Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out,” written with Eric Vohr. An edited version of a two-hour conversation follows.

http://www.nytimes.com/2010/03/09/science/09conv.html