As part of her night shift routine as a charge nurse, Cat reviews all lab values for the patients on

her unit. She found inexplicable changes in a number of patients' sodium values. So she followed her instincts (and her intellect) that something was wrong with the laboratory findings being reported in a large series of patients. Working with the lab, an investigation found that more than forty patients in the Cancer Center had incorrect sodium calculations made. But thanks to Henderson's astute observation and quick action, only one patient was treated for the incorrect results (without any adverse effects).

Vicki championed doing "re-vitals"- that is reassessing patients in the emergency department. In the past two years, she identified significant changes in patients. One was having a heart attack, and the other a stroke. Because of Vicki, these two patients received the required treatment from the heart attack team and the brain attack team earlier than they would have. When minutes count, Jackson's vigilance was life-saving.

Working the tail end of the night shift, Liza was preparing a surgical patient as the first case for the operating room one morning. The patient complained of not feeling well. Liza assessed the patient, whom she identified as having symptoms indicative of an impending stroke. She organized the ophthalmology team and facilitated the patient's transfer to the Emergency Department where the required treatment was rendered in a timely fashion. Her quick assessment and critical thinking provided an immediate intervention so that the patient with an impending stroke was managed in a controlled environment.

The Hospital has been implementing an electronic provider order-entry system requiring all physicians to enter their orders online, and all nurses to document administration of medications in an electronic record. While the system was designed to be safer than paper-and-pencil versions, it was not fail safe. Robertson orchestrated the collaboration between physicians and nurses that was needed to develop the order sets, and implemented the change across the Department of Surgery. Many safety issues have arisen during this process. Robertson monitors these, and drives safety issues to the top of the priority list for system modifications. While many of our safety heroes have prevented individual patients from being harmed, Robertson is working to make the whole system safer.

The conference room was beautiful with a wall of windows as the backdrop of the stage, overlooking pretty Dorchester Bay. The audience consisted of doctors, nurses, health care leaders and public policy people all from the state of Massachusetts. These people had come together to celebrate the movement and to more importantly be inspired to continue on in the improvement of health care delivery at their hospitals. The centerpiece of the event was Charlie Kenney's new book The Best Practice: How the New Quality Movement is Transforming Medicine.

The morning began with a welcome by Cleve Killingsworth, the Chairman and CEO of BCBSMA. It was apparent to me as I listened to him that he and his organization were committed to patient safety. It seemed that BCBSMA was going beyond the call of duty. BCBSMA isn't sitting in the back of the room, merely observing the quality movement, but its leaders are committed to leading the way and I am grateful for that.

After Cleve's opening remarks, I shared Josie's story and my thoughts on Charlie's great book. I recommend this book to anybody interested in learning more about the history of the patient safety movement that is truly changing health care for the better. I hope that the book can raise awareness on the reality of medical errors and inspire people to continue their work to improve patient safety or even to take up the cause.

I could go on and on about the interesting ideas of Charlie and other safety leaders like Don Berwick of IHI, Louise Liang of Kaiser Permanente, Uma Kotagal of Cincinnati Children's Hospital, and Goran Henriks of the Qulturum in Jonkoping, Sweden, but instead I'd like to send you to Paul Levy's blog "Running a Hospital". In addition to being the President and CEO of Beth Israel Deaconess Medical Center in Boston, Paul is an amazing blogger. He was at the conference, and has done an excellent job on writing about the days events. Take a peek.

And so Monday night I had dinner with five people from Health Care for All (HCA). HCA is a Massachusetts-based non-profit organization that is working to- among other things- create greater quality health care throughout the state. You can read all about them on their website. HCA sponsors the Consumer Health Quality Council- a very active and renowned coalition of health care consumers who have been personally affected by medical errors. The Council was created in 2006 and currently has about 40 members who are doing some impressive things: sharing their medical error stories with the public, advocating for improved health care, and meeting with legislators to introduce health care improvements into law.

A recent success included their year and a half-long work in the development and signing of a groundbreaking state law that includes:

For each of the Joint Commission's preventable harm events, BIDMC lists the number of times such an event happened at the hospital within a quarter. Levy's discussion on the motivation and concerns surrounding such a public forum is insightful. The emphasis on reporting the raw number of harm events- and not obscuring them by reporting them as percentages of total patient population- shows a real understanding that patients are people whose lives are truly impacted by preventable errors.

It also sets up a clear standard of comparison; the goal is to have zero preventable events, and anything above zero signals continued room for improvement. What's the bottom line? Big thinking in a simple framework that patients, nurses, doctors and hospital administrators alike can use to chart progress and identify ways to change the status quo and improve patient safety.

The line from Levy's post that struck me the most is the quote used for the title of this post: "Don't think that you are more safe in a place just because they don't talk about their errors." I think this succinctly sums up an important aspect of patient safety today. For years, it was commonly assumed that there was an acceptable threshold for errors in medicine. Then came the realization that harm events could be prevented by analyzing and reworking broken systems. It's a huge change in philosophy, and the exciting part is that as patients and healthcare providers, we are all in the middle of a true zeitgeist shift. The language and tools to move medicine into a new, safer phase are right now being developed at a quick clip, and it will take some time and thought to figure out how we can best use these new resources to improve patient safety.

Surprising news about the incidence of harm events at one institution doesn't necessarily mean that a hospital isn't safe or actively trying to become safer; instead, it's a new way to bring healthcare providers and consumers on the same safety page.

Thanks,

Andrea

For example, here are some good questions we recently received from Wisconsin:

1) What barriers, if any, did you experience from physicians and staff when implementing Condition H? How did you overcome them?

2) How do the nurses and medical staff react when the family or patient calls Condition H? Were there any feelings of guilt (i.e., "I failed the patient") or resentment? What resources are available for staff to debrief after a Condition H call?

3) How many calls do you get from patients or families per month? How many have been appropriate vs. inappropriate?

4) How willing were the physicians to do this? If there were any negative attitudes, how were they overcome?

5) If you have both staff-activated rapid response teams and patient- and family-activated rapid response teams, are the teams the same or do you have unique teams for both?

Are there any Condition H veterans out there who would be open to talking to colleagues in the early stages of implementation?

If you are interested, I encourage you to post below or email me at awesol@josieking.org to volunteer.

I will also set up a discussion page on our forum "Connecting with Others". Click here to enter the forum.

From September 2005 to August 2007, there were 42 calls to Condition H. All of the calls were instigated by breakdowns in communication between caregivers and the patient or the patient's family. As the patient safety movement continues to make great strides and develop new techniques to prevent medical errors, it's clear that basic communication skills remain key resources for both caregivers and patients.

These and other successes are discussed in detail in the May/June 2008 issue of the Journal of Healthcare Quality.

As a Condition H partner, we at the Josie King Foundation are so proud of their success and hope that their impressive results inspire even more hospitals to implement Condition H. As a healthcare consumer, I'm relieved to know that more and more fellow patients have access to these rapid response teams.

Condition H consistently ranks among the top of the inquiries that we receive. It's encouraging to hear from so many institutions in varying stages of implementing patient- and family-activated rapid response teams of their own. For those of you who are associated with hospitals that have active programs, consider sharing any successes or lessons from your experience that could help your patient safety colleagues.

If you are in the early stages of planning, or are just considering starting a similar program at your institution, you can find helpful information on our website. Background material on Condition H is available here. This page also contains program support materials developed by UPMC for their program, like educational brochures and evaluation tools. These materials are all available for download, for you to learn from, amend and use at your institution. Big thanks to our friends at UPMC for sharing their good work with the community.

Please send us your questions and share your stories by leaving a comment below or emailing me at awesol@josieking.org.

Thanks, and more soon,

Andrea

This is where I enter the picture.

My name is Andrea Wesol, and I've been working with Sorrel and Tony for almost four years now. It's been a true pleasure to help them grow the Foundation and expand the scope of the work done in Josie's name. It's also been rewarding to communicate with you- the patients, families and medical professionals who write to us. I am most often the first point of human contact that most people have with the Josie King Foundation, and it's a role that I enjoy tremendously. I'll still be the one responding to your inquiries and ideas about the DVD of Sorrel's speech, Care Journals, Condition H, etc., so keep those emails coming. I do look forward to having the new medium of the blog to interact with you and generate public discussions about the patient safety topics that make this work so interesting.

Fear not- Sorrel will still be contributing to the JKF Blog. For you sports fans out there, think of me as the play by play announcer, and Sorrel as providing color commentary.

You can expect to find more frequent blog posts, so please bookmark this site and come back regularly to check out or contribute to the conversations. I encourage you to leave comments and questions about the blog after each entry, and you can always email me on any patient safety topic at awesol@josieking.org.

More soon,

Andrea