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Vital Signs

Ensuring safety, even in the middle of the night

By Laura Stephenson Carter

Safety is not centralized," says Dr. George Blike, DHMC's patient safety officer. "It's what happens in the middle of the night when nobody is watching."

Patient safety is everyone's business, he insists. "You've got to empower your staff—that's where safety lives," says Blike, an anesthesiologist. "And you've got to invest in prepping people for that and help them have the tools and the means to be successful."

Errors: Patient safety has always been a concern of the medical profession, but efforts to improve quality and patient safety intensified after the Institute of Medicine issued a report in 1999 on medical errors; it estimated that 98,000 hospital deaths every year were due to medical errors. The report noted that the vast majority of errors weren't the fault of individuals, but of systems that didn't work. So medicine began using a systems approach-and an understanding of the interface between people and systems-to help prevent human error.

The aviation industry, for example, has long used a systems approach to safety. In fact, medicine had already looked to aviation; in the 1970s, anesthesiologists began using aviation-style checklists to ensure that they followed the proper steps in administering anesthesia.

Now checklists and many other concepts borrowed from aviation are common at DHMC, as well as at other medical centers across the country.

Another tactic that's made the transition from aviation to medicine is the creation of multidisciplinary teams and of a climate in which all members of a team feel empowered to speak up. "Systems engineering is enhanced by understanding the interplay between human operator and machine-like pilots and cockpit interface," says Blike.

At DHMC, the goals of the patient safety effort include reducing the number of hospital-acquired infections; increasing medication safety; improving communications and coordination; and reducing work-related employee injuries (such as back injuries from lifting patients or blood-borne injuries from needle sticks).

Simple: Some of the solutions are simple. For instance, at DHMC putting soap and sanitizer gel in more convenient locations has brought hand-hygiene compliance before and after caregivers see patients to 86%-which has led to a 27% reduction in health-care-associated infections; the eventual goal is 100% compliance. And increasing the number of employees who get flu shots has helped to prevent the spread of flu.

Other solutions are more complex. Another DHMC initiative-empowering nurses to take action when a patient begins to decline, rather than requiring them to wait for a doctor's okay-has meant that fewer patients have had to be transferred to the ICU.

DHMC also uses training on simulated patients, another concept borrowed from aviation. Dartmouth-Hitchcock recently opened an 8,000-square-foot, state-of-the-art Patient Safety Training Center, where

At the new 8,000-square-foot Patient Safety Training Center, part of a many- pronged safety effort at DHMC, staff and students can practice procedures on life- like manikins: 1 Ob-gyn resident Erron Kinsler has just inserted an IV in this hand. 2 Medical student John Hui is practicing bag-mask ventilation. 3 Technician Gene Streck, right, observes an exam of a pregnant manikin that can actually give birth. 4 Nurse-midwife Lucy Wilson checks a manikin's vital signs. 5 The room layouts are also totally realistic, and the hospital beds and vital signs monitors the real thing.

It's essential to "empower ... staff—that's where safety lives."

employees can practice procedures on lifelike manikins that are programmed to respond just as real patients would. Their blood pressure and respiration change in response to interventions, for example, and they cry, drool, sweat, and bleed.

Try: Providers can try anything from lifting a patient safely to delivering a breech baby. Practice sessions on the manikins can also be videotaped and assessed afterward by trained evaluators.

And it's not just doctors, nurses, and

students who make use of the training center.

Security and housekeeping personnel can practice procedures there, too. For example, security officers can rehearse techniques for "helping with patient restraint when patients are delirious and combative," explains Blike. And housekeeping staff, he says, can learn techniques for "making sure resistant organisms are not left on guardrails [or] knobs, where a lot of bugs live."

But the training center-which Blike likens to a "crash-test" facility-is only part of the safety effort. Safety, he says, "starts with good people who are given the means to be successful and an organization that really values these things."

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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