Field of Work: Health care safety
Problem Synopsis: The Institute of Medicine’s 1999 report To Err Is Human: Building a Safer Health System called for a 50 percent reduction in preventable patient harm within five years. However, although awareness of patient safety has grown, examples of sustained progress have been rare.
Synopsis of the Work: Johns Hopkins researchers created the Public-Private Partnership Promoting Patient Safety (P5S), composed of representatives from government, industry, and nonprofit organizations. P5S used a successful model from the aviation industry—Commercial Aviation Safety Team (CAST)—to identify two of the most common hazards in hospital care, and help devise solutions to them.
Key Findings/Results: Using the CAST model, the P5S team analyzed databases of medical errors and chose two of the most common hazards:
- Syringes used to administer U-500, a concentrated form of insulin given to patients with severe diabetes.
- Infusion pumps used to administer nutrients and medications to patients in hospital emergency rooms, recovery rooms, and intensive care units.
A project team then developed a prototype syringe designed specifically to administer U-500. Allison Medical has commercialized the syringe, and is awaiting FDA approval.
A project team composed of clinicians and engineers also observed medical personnel using infusion pumps, and developed a framework for improving them and testing new ones.