1. 10 years after “To Err is Human” An RCA of Patient Safety Research? Peter Pronovost, MD, PhD

2. Objectives To reflect on some of the barriers to patient safety research To consider an overview for training in patient research

3. Bilateral cued finger movements

5. System Failures Slowing Progress in Patient Safety Failure to view the delivery of care as a science Insufficiently robust research Insufficient partnerships Between academic and quality communities Insufficient capacity to train researchers Reason model Patients continue to suffer preventable harm Reason

6. Translation Superhighway

8. System Failures Slowing Progress in Patient Safety Failure to view the delivery of care as a science Insufficiently robust research Focus on differences rather than similarities with other types of research Insufficient capacity to train researchers Reason model Patients continue to suffer preventable harm Reason

9. Central Mandate Local Wisdom Scientifically Sound Feasible x

10. Exercise Please answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average How smart am I How hard do I work How kind am I How tall am I How good is the quality of care we provide

11. Improving Sepsis Care (n= 19 ICUs) 69% Reduction (p < 0.001) 36% Reduction (NS)

12. Improving Sepsis Care (n= 19 ICUs) 69% Reduction (p < 0.001) 36% Reduction (NS)

13. Framework for Patient Safety Research and Practice Measuring Patient Safety Translating Evidence Intro Practice (TRIP) Identifying and Mitigating hazards Improving Culture and Communication Building Capacity and Organizing for Safety Reducing Diagnostic Errors Pronovost Circulation in press

14. Pronovost BMJ in press

16. Identify Hazards ( 3. Mitigate Risks 2. Analyze & Prioritize Hazards 4. Evaluate Effectiveness of Risk Reduction Patient Safety Learning Communities Patient safety learning communities relate to each other in a gear like fashion: as the identified hazards require stronger levels of intervention to achieve mitigation, the next learning community is engaged in action, eventually feeding back to the group that provided the initial thrust. Each group (unit, hospital, industry) follows the same four- step process, but they engage unique matrices of stakeholders to mitigate hazards that are within their locus of control.

17. System Failures Slowing Progress Failure to view the delivery of care as a science Insufficiently robust research Focus on differences rather than similarities with other types of research Insufficient capacity to train researchers Reason model Patients continue to suffer preventable harm Reason

18. Context become Mechanism Context MechanismOutcome Pawson Tilley

19. System Failures Slowing Progress in Patient Safety Failure to view the delivery of care as a science Insufficiently robust research Focus on differences rather than similarities with other types of research Insufficient capacity to train researchers Reason model Patients continue to suffer preventable harm Reason

20. Simple Rules for Producing Researchers Obtain formal degree Identify willing and capable mentor Obtain protected time to participate in research project

21. Core Skills for Patient Safety Researchers Epidemiology Biostatistics Health services Economics Sociology Psychology Informatics Systems analysis Qualitative Leadership Change management Project management

22. EPI /Stats Psych /Soc HSREcon Critical care Surgery Pediatrics Medicine Quality and Safety Research Group Mixing Bowl

23. Improving Patient Safety in Michigan ICUs Funded by AHRQ

24. 24 Time periodMedian CRBSI rateIncidence rate ratio Baseline2.71 Peri intervention1.6076 0-3 months00.62 4-6 months00.56 7-9 months00.47 10-12 months00.42 13-15 months00.37 16-18 months00.34 2 year results from 103 ICUs Pronovost NEJM 2006

25. "Needs Improvement“ Statewide Michigan CUSP ICU Results Less than 60% of respondents reporting good safety climate =“needs improvement” Statewide in 2004 84% needed improvement, in 2006 41% Non-teaching and Faith-based ICUs improved the most Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

26. Keystone ICU Safety Dashboard 20042006 How often did we harm (BSI) 2.8/10000 How often do we do what we should 66%95% How often did we learn from mistakes 30%100% % Needs improvement in Safety climate Teamwork climate 84% 82% 43% 42%

27. Focus and Execute