Improving the Safety of Patient Care by Looking at the Airline Industry
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.
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.
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- The Patient Safety and Quality Improvement Act Regulations March 1, 2010
- Perfecting Patient Flow January 1, 2005
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