Page 63 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

32 PART 1: An Overview of the Approach to and Organization of Critical Care

death is a leading cause of death. In addition to increased patient morbid-
• Pronovost P, Needham D, Berenholtz S, et al. An intervention to ity and mortality, this crisis of patient safety has increased health care costs
decrease catheter-related bloodstream infections in the ICU. N and lowered public confidence in health care.
Engl J Med. 2006;355(26):2725-2732.
• Singh N, Rogers P, Atwood CW, et al. Short-course empiric antibi- PREVENTABLE VERSUS INEVITABLE HARM
otic therapy for patients with pulmonary infiltrates in the intensive
care unit: a proposed solution for indiscriminate antibiotic pre- The past 10 years have seen a national focus on reducing adverse events,
scription. Am J Respir Crit Care Med. 2000;162:505-511. with an increase in research and interventions designed to ensure that
• Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine- patients are receiving safe and high-quality care. Unfortunately, most
impregnated sponges and less frequent dressing changes for investment and interest in patient safety has been reactive in nature,
prevention of catheter-related infections in critically ill adults: a addressing egregious, although relatively rare, examples of preventable
randomized controlled trial. JAMA. 2009;301(12):1231-1241. harm, such as operating on the wrong body part. Other types of pre-
ventable harm are more common yet also more nuanced. Within the
critical care unit, the acuity and complexity of patient disease lead many
to believe that complications and morbidity are inevitable. Central to
advancing patient safety improvements and optimizing care delivery is
REFERENCES
the ability to distinguish preventable harm from inevitable harm. 4
Complete references available online at www.mhprofessional.com/hall In commercial aviation, all fatal crashes are deemed preventable.
The implicit idea of preventable harm is that an error occurred that
caused harm, but if the error had been prevented, no harm would have
occurred. Health care differs substantially from aviation because it is

CHAPTER Preventing Morbidity in complex and dynamic, and patient conditions not always controllable.
Despite receiving the best-known medical therapies, some patients will
5 the ICU inevitably die or sustain complications. With ever-advancing scientific
knowledge and often expensive technologies, what is inevitable now
Promise Ariyo may be preventable in the future.
Valid measures of preventable harm require clear definitions of the
Theresa L. Hartsell event (numerator) and those at risk for the event (denominator), plus
Peter J. Pronovost a standardized surveillance system to identify both indicators. If the
5
harm (eg, mortality from acute myocardial infarction or pneumonia) is
only partially preventable (as most is), we will need methods to dissect
KEY POINTS inevitable from preventable harm. 6,7
• Fundamental to improving patient safety is the ability to design Clinicians have labeled virtually all harm as inevitable for decades.
systems of care that reliably deliver evidence-based interventions They did so partly because false-positive events (truly inevitable cases
and reduce preventable harm. labeled as preventable) did not help them learn and improve care.
• Translating evidence effectively into practice involves four key Clinicians most often reviewed and learned about morbidity and mor-
tality alone or with other physicians, focusing more on individual skills
processes: and actions rather than on systems or team skills. Such an approach is
a. Summarizing the evidence efficient for physicians; it is very specific (truly inevitable cases labeled
b. Identifying local barriers to compliance as inevitable) but it is not very sensitive (truly preventable cases labeled
c. Measuring performance as preventable).
Although this approach misses many patients who experience pre-
d. Ensuring that all patients receive the therapy ventable harm, reviewing the cases identified as preventable can provide
• A culture of teamwork is vital to improving the quality and safety useful information. Recent efforts by payers, such as the Centers for
of care provided to patients. Medicare & Medicaid Services (CMS), have gone to the other extreme
• Significant investment in a patient safety infrastructure is required by labeling all harm as preventable. Examples include measures of
overall hospital mortality, the Institute for Healthcare Improvement
8,9
to fulfill a commitment to safe and high-quality care. (IHI) global trigger tools for measuring adverse events, and most of
10
• Chosen quality measures should be clinically important, scientifi- the “never events” identified by the CMS. Both approaches have risks
11
cally sound (valid and reliable), useful, and feasible. and benefits.
• An ICU quality and safety scorecard can be developed locally to
demonstrate a broad overview of patient safety performance over ■ THE SCIENCE OF SAFETY
time, or relative to a benchmark. The gap between medical breakthroughs and patient harm remains
significant because little has been done to study and improve the actual
science of health care delivery (Fig. 5-1). We have made minimal invest-
A QUESTION OF SAFETY ments in the basic science of patient safety. In the United States, for every
dollar the federal government spends on traditional biomedical research,
A decade after the To Err Is Human report, the global health care commu- they only allocate 2 cents to research ensuring patients actually receive
1
nity still struggles to state definitively whether patients under our care are these treatments. Directing resources to advance the science of safety
12
safer. An estimated 98,000 fatalities result from medical errors every year would allow us to better understand the causes of harm, would support
in the United States. That number at least doubles if nosocomial infec- the design and testing of interventions to reduce harm, and would pro-
2
tions and other sources of preventable harm are included. This statement mote robust evaluation of the effects of harm. Instead, examples of large-
4
is true despite amazing advances in biomedical science that have led to scale quality improvements are rare and methods to evaluate progress in
cutting-edge, lifesaving therapies—in part because patients receive only quality are virtually nonexistent. This lack of data to analyze, understand,
about 50% of recommended evidence-based interventions. Although the and ultimately improve health care is a complex local and national prob-
3
epidemiology of preventable harm is an immature science, preventable lem. Most importantly, patients remain at risk of harm.

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