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INTRODUCTION

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The Institute of Medicine's To Err Is Human (National Academy Press, 2000) called for a 50 percent reduction in medication errors, but in 2009, Dr. David Bates said, "With respect to the 50 percent reduction, the truth is that we don't really know, because we don't have good metrics for sorting out how common medical errors are in most institutions." Atul Gawande reported in Complications (Holt, 2003) that autopsies turned up major misdiagnoses as the cause of death a shocking 40 percent of the time, and rates have not improved since 1938.

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Every hospital seems to have the same issues: preventable adverse events that will no longer be paid for by Medicare and other insurers.

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This shows up in many ways:

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  • Catheter-associated urinary tract infections (CAUTIs)

  • Bloodstream infections (BSIs)

  • Surgical-site infections (SSIs)

  • Pressure ulcers

  • Surgical errors: retained foreign objects, surgical infections, and wrong-site and wrong-patient surgeries

  • Blood incompatibility

  • Ventilator-acquired pneumonia (VAP)

  • Patient falls

  • Medication errors

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A recent RAND study found that only one of every two patients will receive care that meets generally accepted standards: 30 percent of stroke patients, 45 percent of asthma patients, and 60 percent of pneumonia patients. In 2009, the Centers for Disease Control and Prevention (CDC) estimated that 1.7 million healthcare-associated infections (HAIs) resulted in 99,000 deaths (271 per day—this is equivalent to a 747 crashing every day) and an additional $35.7 billion to $45 billion in unnecessary costs per year. Between 2004 and 2006, 238,337 preventable deaths occurred involving the Medicare population. In addition, 4.5 patients per 100 admissions will acquire an infection while in the hospital. Types and number of HAIs and estimated costs per patient are as follows: SSIs—290,485 at $34,670; BSIs— 92,001 at $29,156; VAP—52,543 at $28,508, UTIs—449,334 at $1,007; and Clostridium difficile-associated disease (CDI)—178,000 at $9,124.

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Question: What one element is critical to both improved outcomes and patient satisfaction?

Answer: Reducing defects (i.e., medical mistakes) from the current 30,000 patients per million (PPM) to 3 PPM.

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MEMORIAL HERMANN CASE STUDY

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We can't make our employees perfect, but we can develop processes that encourage a level of mindfulness that enables us to catch potential errors before they do harm.

—FROM MEMORIAL HERMANN WEBSITE

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In 2006, Memorial Hermann Health System implemented a high-reliability organization (HRO) program called "Breakthroughs in Patient Safety (BIPS)" using experts from nuclear power, commercial aviation, and other HROs to teach employees how to perform tasks in a safe, highly reliable manner. Becoming an HRO requires implementation "from the boardroom to the bedside."

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Memorial Hermann's quality and patient safety results are impressive. Working across nine acute care and two rehabilitation hospitals plus over a hundred ambulatory facilities, Memorial Hermann has chased the goal of zero harm. From 2007 to 2013, more than 827,000 transfusions were administered with zero cases of blood incompatibility. Several ...

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