Hopkins' little fixes add up to big change

October 29, 2002|By Edward D. Miller

EVIDENCE MOUNTS from the nation's hospitals that the weakest link in patient care isn't medical practitioners but flawed systems.

Historically, mistakes or poor outcomes have been blamed on the "dumb doctor" or the "dumb nurse." This usually has led to the "ABP reaction" -- Accuse, Blame and Punish.

But as we are discovering, inefficiencies and errors in medical centers mostly can be traced not to one error, but to a cascade of events involving multiple procedures and policies, ineffective technologies and insufficient training.

Medical centers need to take a hard, step-by-step look at areas that affect patient safety and complex medical care.

Several years ago, in light of a growing shortage of nurses and increased costs associated with specialized care, we asked: "Are there better, more efficient ways to use the nurses we have to improve patient care?" That led to a broader examination of patient procedures.

At about the same time, the Institute of Medicine issued a report on the large number of medical errors in hospitals nationwide, many of them preventable. This accelerated our efforts to reinvent the way we deal with patients.

To that end, we established the Center for Innovation in Quality Patient Care to systematically examine how we relate to Hopkins patients.

Working with physicians, nurses and others who know their units intimately, the center leadership is identifying weak points and implementing changes that have made a difference.

For example, a detailed audit in an intensive care unit uncovered mistakes in listing medications and allergies when patients were moved to other units.

So the ICU tried a new approach: Nurses match prescriptions and allergies on the written orders with what patients have been getting. Any discrepancy is resolved with the physician before the patient is transferred.

The problem has virtually disappeared.

A close look at the grand tradition of patient rounds revealed that they brought patient care to a standstill. The attending physician, interns and residents would discuss patients' prognosis and treatment as they toured a unit, but they would not order X-rays, blood work and treatments until the end of those rounds.

This created a daily avalanche of requests for tests and new prescriptions, clogging order entry systems, increasing the likelihood of slip-ups and delaying services to patients.

A pilot project in one cancer unit now uses a computerized data cart wheeled to the bedside during rounds. Physicians order tests and prescriptions right then, on the spot. No mix-ups, no clogs, no delays.

Top executives at Hopkins have "adopted" hospital units. There are a million ways to say "no" to change in a large institution, and the goal in these adoptive units is to knock down the roadblocks. The executives make extensive, periodic visits, listen to what's bothering doctors, nurses and technicians and heed what they say is needed to improve patient care.

If we've learned anything, it's that simple changes can make a huge difference.

Such as providing cell phones to nurses caring for infants in isolation rooms so they don't have to leave their tiny charges, re-gloving and re-gowning each time, to take phone calls from worried family members.

Or placing tympanic thermometers and phones in every ICU area so nurses can spend more time with patients.

The excitement generated by our early success shows we are on the right path.

Edward D. Miller, a medical doctor, is dean and CEO of the Johns Hopkins School of Medicine.

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