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Annual Reports on Quality

Eleventh Annual Report on Quality

Introduction

Hospitals should be the safest places in the world. The annual statistics about errors that result in harm to patients are proof that they are not. Why aren’t they? Yes, our hallways are filled with caring, skilled, well-intentioned professionals who can save patients’ lives and make those lives better than they were before. And yet the ever-widening array of treatments, technology, and medications makes each one of us in health care vulnerable to missteps or oversights that can cause harm to the people we are trying to help.

A hospital is a complex, high-risk environment. We are often required to make critical decisions under severe time limitations and incomplete information—and as human beings, none of us is perfect. We all will make mistakes. Our main challenge now is to minimize those mistakes and minimize the harm or potential harm that could occur to our patients. At Crozer-Keystone Health System (CKHS), we believe that our path to success in this challenge begins with a culture of safety. A culture of safety is one that stresses communication, teamwork, and diligence. It’s not about blame, but it is about accountability, with safety being viewed as the responsibility of everyone in the organization.

Like other high-reliability organizations such as aviation and nuclear power—organizations with systems in place to avoid potentially catastrophic errors while accomplishing their goals—we must be looking for defects and errors so that we can learn from them. Only in this way can we prevent them from happening again and causing harm to our patients. Rather than speaking in hushed tones or in darkened rooms behind closed doors, we believe in speaking more openly so that we can learn from each other.

You may have heard this expression before: “Every system is perfectly designed to achieve the results it gets.” When our results are not what we wish them to be, we must take a critical look at our systems of care and be willing to make changes. “Designing safe systems of care” is what this 11th Annual Report on Quality is all about.

First, this Report shares the thoughts of two truly world-renowned experts on patient safety and health care quality: Atul Gawande, MD, MA, MPH, and James Bagian, MD, PE. Together these physicians are a rich source of wisdom about how our health care system can reexamine its processes of care to make sure that no patient is ever harmed—especially in this era of unprecedented and ever-growing complexity. We were incredibly fortunate to have both of them speak to us at our annual CKHS Quality Retreat this past spring. Their ideas are so important in shaping our thinking about safety that we have decided to share their main points with you in Section 1.

In Sections 2 and 3, you will read about our own efforts at CKHS to design safer systems of care. Section 2 presents a selection of case studies that highlight our willingness to find and recognize problems that could harm or have harmed patients—and then work together to prevent them from happening again. As in past Annual Reports on Quality, Section 3 presents the results of our Evidence-Based Medicine projects, all of which are designed to ensure that patients receive the best possible care in accordance with the latest medical evidence.

Just as we work to encourage openness about patient safety within CKHS, we are committed to openness with the members of our community. The Annual Report on Quality is an important symbol of this commitment. We want the people we care for to know that we take their safety seriously, and we believe in sharing frank information about our efforts to ensure quality and safety.

Eric Dobkin, MD, FACS, FCCM
Vice President, Quality and Patient Safety
Crozer-Keystone Health System