Article pp

International Journal for Quality in Health Care 2003; Volume 15, Supplement 1: pp. i31–i40 10.1093/intqhc/mzg075

Improving patient safety across a large
integrated health care delivery system
ALLAN FRANKEL1, TEJAL K. GANDHI2 AND DAVID W. BATES1,2
1
Partners HealthCare System, Boston, MA, 2Brigham and Women’s Hospital, Boston, MA, USA

Abstract
Objective. Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety
across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare
system, a large, integrated, non-proWt health care delivery system in the United States.
Design. Partners identiWed a central Patient Safety OfWcer, who then formed a Patient Safety Advisory Group with local expert
members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member

Downloaded from http://intqhc.oxfordjournals.org by on May 30, 2010
institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implemen-
tation. There was broad consensus that interventions should include the areas of culture change, process change, and process
measurement.
Setting. A large, integrated health care delivery system in the Boston, Massachusetts, area.
Results. Key milestones to date include implementation of Executive WalkRounds, development of accountability principles,
agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physi-
cian order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network.
Most inXuenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient
safety initiatives.
Conclusions. This loosely integrated delivery system represents a daunting landscape for the development and institution of
patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for signiW-
cant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging.
Moreover, with many potential interventions, and limited resources, prioritization and selection is difWcult. Nonetheless, con-
sensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the
net result will be substantial improvement in patient safety.
Keywords: culture, patient safety, quality improvement

Safety in health care has received substantial attention in the be possible even without changing technology [3]. The ultimate
US since the 1999 Institute of Medicine report, To Err Is goal in culture change is system transparency, deWned as a will-
Human [1]. While that report described the magnitude of the ingness of providers and patients to openly and comfortably
problem in some detail, it provided only a high-level view of express their concerns about the delivery of care in a manner
how organizations might change in order to improve the care that identiWes Xaws and leads to their elimination, mitigation, or
they provide. In the 4 years since that report, organizations appropriate management. Culture change, and the subsequent
have struggled to develop coherent programs for improving increase in event identiWcation that it promotes, are essential in
safety, and these programs have varied substantially. order to then be able to identify and improve systems of care
We believe that patient safety programs should include at such as medication delivery. Leadership understanding of
least three areas of focus: culture change, process change, and safety concepts represents an essential component for this cul-
process measurement. Changing culture is a new watchword in ture change [4–7]. Yet it is far from clear how best to build a
patient safety. There is a growing realization that the beneWts of culture of safety, especially across a large entity, or to know
technological advances will be optimized only if health care whether one has been achieved.
providers approach delivery of care from the appropriate Processes need to be standardized and variation reduced to
perspective [2], and that substantial improvement in safety may improve the quality of care and reduce error rates. In some

Address reprint requests to David Bates, Brigham and Women’s Hospital, BC3, 1620 Tremont St, Boston, MA 02120, USA.
E-mail: dbates@partners.org

International Journal for Quality in Health Care vol. 15 Supplement 1
© International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved i31

A. Frankel et al.

instances, this may involve implementation of technology, for safety made identifying the participants for this group
while in others it may not. Process and outcomes must be straightforward, as all the institutions had clearly delineated
measured to know whether care has ultimately been who was responsible for their patient safety efforts. Members
improved. The objective of this paper is to delineate the com- of this group include physicians, nurses, and risk managers.
ponents of a patient safety strategy, developed and imple- Initially, the Patient Safety Leaders Group was most pow-
mented in one large integrated delivery system, to improve erful in educating its members about the good ideas and best
safety by catalyzing safety-based cultural changes, changing practices of each institution. As the group has become more
processes, and measuring outcomes. cohesive, over a period of 1 year, the members are beginning
to think collaboratively about goals for the integrated delivery
system in addition to each individual’s speciWc hospital goals.
Study design To develop the camaraderie necessary to achieve this, the
group has met face-to-face for over a year. Because the inte-
Study site grated delivery system is spread across much of eastern
Massachusetts, initial attempts to convene this group were
Partners HealthCare is the largest integrated delivery system done virtually—usually by telephone conference calls. It
in the north-eastern United States. It was founded in 1994 by became apparent after a few months that the group was not
Brigham and Women’s Hospital and Massachusetts General functioning effectively, so face-to-face meetings were sched-
Hospital, and has grown to include primary care and specialty uled. The improvement in collaboration, camaraderie and

physicians, community hospitals, the two founding academic congeniality was apparent within a few sessions. As a com-
medical centers, specialty facilities, community health centers, promise, the meetings are scheduled monthly, alternating
and other health-related entities. While researchers within between virtual and face-to-face formats.
Partners have long been leaders in patient safety research [8–13], The group is beginning to tackle a variety of system-wide
Partners did not have a coherent, network-wide approach to projects, some aimed at cultural change, such as promulgating
patient safety before the Institute of Medicine’s report. the acceptance of executive WalkRounds to discuss safety
issues and system-wide accountability principles. Others are
process-speciWc, such as managing anticoagulation, improv-
Partners patient safety program structure
ing the safety of central line insertions, and ensuring wide-
In 2000, Partners Chief Medical OfWcer and Partners Chief spread implementation of computerized physician order
Executive OfWcer decided to create the position of Partners entry. These projects were chosen because they address high-
Patient Safety OfWcer. The main task of the position was to risk processes and could be used as paradigms for future
devise strategies to reduce error in care delivery. A signiWcant projects relating to both medication delivery and invasive
component of medical error reduction up to that point had procedures in other areas.
been directed towards measurement and process change, par- In addition to the clinical care provided by Partners and
ticularly in terms of medication safety [11,14,15]. However, non-Partners Harvard-afWliated organizations, these institu-
experiences in attempting to improve safety across a broad tions have been leaders in patient safety research, and the
array of institutions suggested that combined tools that research groups interact closely with the operational entities.
addressed cultural change and leadership as well as speciWc The intent is to have the organizations serve as laboratories
components of care delivery would be most successful [5]. for improvement in patient safety, and in addition to rapidly
The goals delineated for the Partners Patient Safety OfWcer disseminate beneWcial changes throughout the organization.
position included speciWc efforts to change the culture of our
hospitals—especially by educating hospital leadership—and
to revise the hospitals’ methods of analyzing adverse events
so that they measure and delineate system and process prob-
Results
lems, pinpoint longstanding unsafe traditions, and delineate
Patient safety initiatives across an integrated
actions to address them.
health care system
Two groups were developed to support the Partners
patient safety effort. A Partners Patient Safety Advisory Integrated delivery system executive-level patient safety goals
Group was convened to meet two times per year to advise the differ somewhat from those established at a hospital-based
Patient Safety OfWcer of national trends and to evaluate the patient safety level. Projects that target transitions from one
efforts underway in the integrated delivery system. The indi- institution to another or require consensus across organiza-
viduals in the advisory group were chosen based on their tional boundaries will beneWt from oversight at a high level.
work in areas related to patient safety, their knowledge of the Coordinated anticoagulation management is an example. By
national environment, and their stature within the Partners contrast, initiatives that are wholly hospital based or con-
HealthCare System. In addition, a Partners Patient Safety tained within one organization or one administrative structure
Leaders Group was convened, made up of the individuals in can be piloted and proven locally. Then other hospitals may
each institution with the responsibility for patient safety. The beneWt from the learning. However, hospital-based patient
Joint Commission on Accreditation of Healthcare Organiza- safety personnel tend to be, appropriately, inwardly focused
tions’ mandate that hospitals identify a locus of responsibility and their time is Wlled with responsibilities from within their

i32

Improving patient safety

own organization. As a result, the opportunity to learn from organization created to help lead the improvement of health
other organizations is limited to literature and an occasional care systems and to promote continuous increase of their
national conference. Lack of collaboration across and within quality and value [17]. The IHI has conducted many year-long
institutions is common. The strength of an integrated system multi-hospital collaboratives to develop and spread best prac-
is that its leaders can develop a framework for constant col- tices. In these collaboratives, up to 140 hospitals over a period
laboration to occur. The Patient Safety Leaders Group has of 1 year undertake similar projects aimed at improving health
been an example of this. The relationships developed have care, and convene periodically to discuss and compare their
facilitated large-scale projects as well as fostering numerous progress. The WalkRound™ tool was designed to connect
collegial interactions about smaller problems. Safety requires senior leadership to patient safety and to inculcate a culture of
collaboration amongst clinical groups and should be a goal of safety into the health care system. It was also postulated that
all those responsible for patient safety. the information elicited during the WalkRounds™, if effec-
The aim of the new Partners-wide safety goals was to achieve tively analyzed, might be used to drive safety-based changes
a culture change, and to revise the hospitals’ methods of analyz- by creating a cycle of information–analysis–action–feedback.
ing adverse events to include process change and process meas- The end result would be a self-sustaining process that would
urement. To accomplish these goals, our approach has been continue to engage leadership, educate clinicians and mana-
initially to pilot an intervention at one institution with the goal of gers, and lead to continuous improvement.
eventual rollout across the entire delivery system. The interven- The WalkRounds™ were initiated with the following object-
tions that have been piloted and/or implemented in the system ives: (i) to increase awareness of safety issues by all clinicians;

have included executive WalkRounds™, the development of (ii) to make safety a high priority for senior leadership; (iii) to
accountability principles, Web-based reporting systems, and educate staff about patient safety concepts such as non-puni-
process-speciWc initiatives. Separately, they are modestly useful. tive reporting; and (iv) to obtain and act upon information
Combined, however, these initiatives are a signiWcant force. elicited from staff about safety problems or issues.
Table 1 outlines some of our current and potential patient safety WalkRounds™ was piloted at one hospital in January 2001.
initiatives; the challenge is determining the priority for implemen- The Chief Executive OfWcer, Chief Operating OfWcer, Chief
tation of each of these initiatives. Medical OfWcer, and Chief Nursing OfWcer agreed to partici-
pate in weekly safety walk rounds. Other participants in the
WalkRounds™ include the patient safety director, patient
Culture change: executive WalkRounds™
safety manager, and research assistant. WalkRounds™ are
Executive WalkRounds™ were conceptualized initially in the held weekly and visit different areas of the hospital, including
Idealized Design of Medications Systems Design Group at the medical/surgical/obstetrical wards, emergency room, phar-
the Institute of Healthcare Improvement in 1999 [16]. The macy, and operating suites. During the WalkRounds™,
Institute for Healthcare Improvement (IHI) is a not-for-proWt speciWc questions are asked of the staff nurses, residents, and
staff pharmacists on duty, such as ‘Were you able to care for
your patients this week as safely as possible? If not, why not?’
Table 1 Partners current and potential patient safety initiatives and ‘What could this unit do on a regular basis to improve
safety?’ (Figure 1). At the end of the rounds those who were
Culture change questioned are educated about patient safety concepts such as
Executive WalkRounds™ the importance of reporting near misses and how thinking
Accountability principles or commitments about human factors can inXuence decision making. These
Education: orientation, competencies, credentialing participants are e-mailed a transcript of the conversation later
Safety brieWngs that day to thank them for their participation and so that they
Core process may review their comments. Events that are captured in these
Intelligent Information Technology: computerized rounds are put into a database and classiWed according to the
physician order entry, electronic medical records, contributing factors that inXuenced the event. Each event is
computerized medication administration records, assigned a score based on its severity or its potential for
bar-coding patient harm.
Simulation: teamwork and communication The list of events requiring active response is prioritized by
Flow: unit-based assessment level of severity and brought to the responsible leadership,
Protocols: clinical practice guidelines by evidence and and ownership of the issues is assigned. Each quarter,
consensus the leadership provides updates to those who participated in
Hardware standardization the rounds on progress towards resolution or a statement of
the rationale for not taking action. Informing them of the
Measurement
actions taken closes the communication loop with the
Reporting systems
Pharmacy interventions WalkRound™ participants. We have informally surveyed
Computerized monitoring for adverse events staff and leadership about these walk rounds. Leadership have
been extremely engaged and feel the rounds have great value.
Protocols and clinical practice guidelines
The staff overall have been pleased to see leadership commit-
Attitudinal surveys (clinician and patient)
ment to safety with these rounds, and have been pleased with

i33

A. Frankel et al.

Sample questions:
1. Have you been able to
care for patients as safely
as possible. If not, why?
Weekly 2. Have there been any near
misses that almost caused
WalkRounds patient harm?
with 3. Can you describe the
unit's ability to work as a
leadership team?
and staff 4. When you make an error
or intercept an error, do you
always report it? If not, why?
5. Have you discussed
patient safety issues with
Monthy your patients or their family
members?
reports
prioritized
by severity
of patient
impact
Feedback to the

reporter
Responsible
clinical
manager
and
leadership
review
No

Decision
for action

Yes

Assignment of
ownership

Action
completed

Figure 1 WalkRounds™ Xow diagram.

the follow-up actions they see based on their comments. Reporting System (ASRS) is an example of this successful
Since the initial pilot, WalkRounds™ have been successfully approach applied to the airline industry [18].
implemented at four additional Partners institutions. The plan Currently, reporting of adverse events frequently does not
for further spread to other institutions is under discussion, as occur, at least in part because individuals believe that they will
is a standardized analysis of the impact of the WalkRounds™. be blamed or sanctioned (regardless of whether the individual
In addition, a study is underway to evaluate the WalkRounds or the system is at fault) [19]. Most blame-free policies
in 10 other Massachusetts hospitals over the next 2 years. attempt to balance the desire to increase reporting with the
desire not to limit sanctions. This is usually done by promis-
ing protection to those who report in a timely fashion and
Culture change: accountability principles
exempting cases of misconduct. Many are fashioned from the
Accountability principles or commitments to safety derive ASRS reporting procedures that have for over 25 years
from attempts to clearly enunciate a non-punitive or blame- offered immunity if reports are obtained within 5 days of the
free reporting policy towards health care providers who event, exempted criminal actions, and afforded the reporter
report adverse events or episodes of patient harm. The pur- conWdentiality, followed 30 days later by anonymity. The
pose of improving reporting is to elucidate Xaws in the health ASRS system works on a national scale, but does not offer to
care delivery system that may then lead to the development the individual airlines an analysis of airline-speciWc problems.
and implementation of system remedies. The Aviation Safety To address this, airlines have built Aviation Safety Action

i34


Plans that tend to offer conWdentiality but not anonymity and attitude and unsafe Xying conditions. These surveys have
that facilitate in-depth root-cause analysis. been modiWed for use in health care and there are clear
Anonymity and conWdentiality in a hospital or health care indications that provider attitude may be correlated with
system is much harder, sometimes impossible, to achieve. patient morbidity and mortality [25,26]. We are planning to
Rather than simply address the protection afforded to individ- use these types of surveys to measure the cultural impact of
uals for reporting, a set of principles that outlines expectations WalkRounds™ and Safety BrieWngs.
of all the stakeholders regarding system-versus-individual
responsibility may be what is needed. If written intelligently,
Process change: high risk processes
a set of principles or policies about reporting harm does not
require health care institutions to compromise their ability to Standardization and simpliWcation of care through intelligent
police employees or appropriately prosecute misconduct. protocols and clinical practice guidelines has been a staple of
The Partners Healthcare System has been developing this quality improvement for a few decades in health care [5], but
set of principles with the hope that every member institution has had variable and often poor penetration. The relationship
supports them and fosters a similar attitude regarding culture, between complexity and error, delineated in human factors
reporting, and accountability. The Partners Patient Safety research in many industries, has led to increased vigor on the
OfWcer and Patient Safety Leaders Group initially drafted the part of health care safety advocates to implement process
accountability principles by performing a search of the litera- standardization, including through the use of protocols. The
ture to Wnd non-punitive policies currently in use in health major efforts of the Partners Patient Safety OfWcer have tar-

care. ‘Whistle-blower’ statutes were reviewed and state- geted anticoagulation management, the placement of central
speciWc issues about peer review protection identiWed. The venous catheters, and computerization of physician ordering
Patient Safety Leaders Group reviewed the principles, followed in the in-patient setting.
by risk management and human resources representatives
from each Partners institution as well as by Chief Medical and
Anticoagulation
Chief Nursing OfWcers. In addition, hospital lawyers and
human resource departments piloted the initial drafts by Perhaps the most compelling evidence supporting the impor-
applying them to selected cases to ensure that they did not tance of protocols is in the management of anticoagulants,
conXict with appropriate hospital actions. Newer drafts were especially heparin and warfarin [27]. All of the Partners hospi-
evaluated in a similar way. An appendix to this paper shows tals currently use some form of a heparin weight-based proto-
the version of the principles approved by all the Partners col for at least some patients and we have numerous warfarin
institutions. clinics within our loosely integrated delivery system. How-
ever, many patients on warfarin are not managed in a clinic
setting, and a system-wide program for warfarin management
Culture change: future initiatives
has been lacking. Systematic warfarin management is neces-
The Executive WalkRounds™ and accountability principles sary to provide effective care to patients during transitions
represent the foundation for cultural change. Educational from one level of care to another.
modules about safety, ‘Safety BrieWngs’, and attitudinal To improve these processes, we convened a group of inter-
surveys are other building blocks under consideration for ested individuals and experts including physicians, nurses,
implementation. Safety BrieWngs involve frontline staff, and pharmacists, information technology specialists, in-patient
are simple and brief interchanges usually conducted during discharge planners, home care specialists, ofWce business
transitions in care—either as patients are transferred or as managers and outpatient anticoagulation service providers.
health care providers change shifts. These brieWngs identify The mission of this group is to: (i) centralize information
speciWc areas of risk at the time of the brieWng and should be about patients and their anticoagulation status while support-
conducted in a relaxed but formalized fashion. ing local control and management; and (ii) decrease the
The educational component of culture change occurs dur- number of steps necessary to manage anticoagulation, thereby
ing orientation of new employees, and during re-credentialing decreasing the likelihood of error. To accomplish these goals,
and competency training of all health care providers. The the group is currently designing software to serve a dual pur-
education will include: (i) human factors—how humans inter- pose: to assist large warfarin clinics that primarily manage lab-
act with their environment [20]; (ii) cognitive psychology— oratory data and drug dosages, and also to support small
how humans think and how we make errors [20,21]; (iii) how ofWce-based clinics who see patients face-to-face. The needs
innovative ideas diffuse [22]; and (iv) ethics and accounta- of these two types of clinics differ, but they have a common
bility—the logic in making complex systems transparent [23]. requirement: anticoagulation information should be readily
We are currently planning a curriculum for all new employees available from anywhere in the delivery system.
(in particular clinicians) to focus on these issues. The second goal, to decrease the steps in management,
Attitudinal surveys offer another opportunity to measure may be accomplished by using point-of-care blood testing
the degree of transparency and open communication being devices to measure the international normalized ratio (INR)
fostered by patient safety projects in an institution. Surveys rather than the standard mechanism, i.e. obtaining a vial of
used in this fashion are commonplace in the airline industry blood and sending it to a laboratory for INR analysis. The
[24,25]. They have shown a direct relationship between pilot group is also evaluating supports for physicians and patients

i35

A. Frankel et al.

who are not attached to current ofWce and hospital anti- Safety Leaders Group will be an important entity for sharing
coagulation clinics. A model for geographically diverse care information about successes and barriers as CPOE moves
that manages patient transitions well is the visiting nurse forward.
association (VNA). Partners HealthCare system is looking
to these groups to develop ambulatory clinic-based models
Process change: future initiatives
to manage anticoagulation using point-of-care testing
devices. Core process changes include the intelligent structuring of
Measurement of current effectiveness is underway, with information technologies, simulation, standardization, and sim-
plans to audit process measures (percent of patients with pliWcation of care delivery through protocols and clinical prac-
therapeutic INRs) and outcome measures (bleeding- and tice guidelines, streamlined patient Xow with fewer delays, and
clot-related complications). Independent physician groups hardware standardization. Into this Wnal category falls CPOE,
are particularly difWcult to monitor as each maintains its own standardizing warfarin management during transitions of care,
databases, often on paper, and they have not been required and protocols for safe central venous catheter placement.
to collect or maintain this information. A one-time audit sug- Other projects in this category are also being evaluated.
gested that the percentage of patients maintained in thera- Boston has been a stronghold of simulation research spear-
peutic INRs by the groups ranged from 45 to 75%. We headed by the Center for Medical Simulation. In the simula-
believe that 75% of patients in therapeutic INR is an appro- tor, models of patients’ rooms or invasive suites and
priate goal for each physician group; our plan is to ask each operating rooms are combined with computer-driven moni-

group to collect the information in the manner easiest for them. tors and manikins to simulate real-life problems. Students
have the opportunity to learn and test their skills in a safe
environment where patients cannot be harmed and actions
Central venous catheter insertion can be critiqued. Simulators are available relatively inexpen-
sively for placement in every hospital, and have the potential
Evaluation and spread of best practices in central venous
to dramatically improve teamwork, open communication and
catheter (CVC) insertions is a system-wide project under-
provider education. Partners and the Center for Medical Sim-
taken by the Partners epidemiology leaders, the goal of
ulation are embarking on many projects that will impact each
which is to decrease complications, especially CVC-associ-
institution. For example, anesthesia residents are all undergo-
ated blood stream infections. Practice around CVC insertion
ing simulation training in return for which their malpractice
varies widely from one intensive care unit to another, even
insurance premiums have been reduced. Under discussion is
though physicians rotate through the entire delivery system.
further development of in-hospital simulators for use in
During CVC insertions, having in attendance an un-
teamwork and skill-based training.
scrubbed assistant and an experienced attendant or fellow
In addition to CPOE, information technologies such as
has been historically difWcult to institute. Epidemiologists
electronic medical records, automated medication administra-
and intensivists have instituted and spread best practices
tion records and bar coding are all currently in use in some
using education, protocols, and audits. The focusing of
Partners settings and are becoming more widespread
attention combined with the pilot study facilitated spread of
throughout Partners Healthcare System. However, having a
the best practices with excellent results. One organization
logical strategy for implementation is the key to acceptance of
with incomplete penetration of the suggested practices, after
these new technologies, and Partners Information Systems is
fully adopting these practices, decreased the central line
putting signiWcant effort into creating a common information
blood stream infection (BSI) rate over a 12-month period
technology structure for the entire network.
from 162 to 120, yielding a calculated saving of $2.5 million.
Patient Xow is another possible area of intervention. Given
The rates placed the institution in the top quartile of organi-
our current nursing and pharmacist shortage, empowering
zations compared with the Centers for Disease Control and
nurse managers and frontline nurses to control patient Xow
Prevention benchmark rates.
based on safety is imperative. This may be accomplished using
innovative strategies such as the unit assessment tool used by
Luther Middlefort Hospital in Eau Claire Wisconsin, in which
Computerized physician order entry
frontline nurses use a trafWc light concept to delineate the state
Computerized physician order entry (CPOE) has been found of safety on their unit. Hospital workers use red, green, and
to substantially decrease the rate of serious medication errors yellow colors to identify the level of risk they perceive in their
[14,15], and appears to be one of the most potent technolog- area based on parameters such as nurse:patient ratios and
ical changes for improving patient safety [28]. While CPOE patient acuity. The colors are broadcast through the institution
is in place in the two large teaching hospitals in the Partners as the screen-saver on the hospital computers and determine
network, it has not yet been implemented in the smaller hos- where patients are admitted and transferred. Resources are
pitals. Because of the recommendations of the Partners diverted to aid those areas in the ‘red’ zones [29].
Patient Safety Advisory Group regarding the substantial Finally, standards are necessary that direct hardware pur-
safety beneWts of CPOE, the Partners leadership has made a chases based on safety. Medication infusion pumps are a sen-
commitment to the implementation of CPOE in all in- tinel example in this category. Testing for human factor
patient institutions over the next few years. The Patient problems should determine the choice of pumps, favoring

i36


those that have ‘intelligent’ but simple redundancies to alert Process measurement: adverse drug event
the care provider. There are currently numerous pilot tests monitor
underway in the Partners Healthcare System to evaluate and
Patient safety will be improved further by the implementa-
standardize these technologies.
tion of routine measurement across a variety of domains.
The common reporting system will be a vital tool in this
Outcome measurement: a common reporting regard. However, spontaneous reporting detects only a small
system minority of events [32,33], and we believe that automated
detection methods will be useful in improving routine detec-
Another key to a culture of safety is having an easily availa-
tion of safety issues [34–36]. A computerized Adverse Drug
ble and simple way for health care workers and patients to
Event Monitor that searches for signs of an adverse event
report adverse events. Critical components of a safety
and sends this information to a pharmacist for follow-up is
improvement program in a large delivery system are the
now in routine use at one hospital [37]. The monitor is a pro-
adoption of a common language for reporting errors and
gram (consisting of > 30 triggers) that searches the patient’s
near misses, and an ability among hospital staff members to
computerized medication and laboratory test proWles for evi-
learn from each other. The goal of Partners is to create a
dence of adverse drug events and generates alerts. An exam-
common reporting system for all member institutions, so
ple of an alert would be a patient whose creatinine is rising
that information can be rendered anonymous and shared
taking an aminoglycoside. The monitor generates a daily list
conWdentially to promote measurement, learning, and

of these alerts and the hospital pharmacists review the alerts
benchmarking. To accomplish this, Partners has opted to
for their patients and make interventions. Most interventions
promote the use of a Web-based reporting system, and has
involve calling the physician to discontinue or change the
been evaluating those commercially available [30]. The use-
dosage of a medication; the goal is to intervene before the
fulness of these kinds of systems relies on the simplicity of
adverse drug event becomes serious or prolonged. This also
the data entry method, the system’s ability to receive and
promotes a culture of safety within pharmacy by actively
store a large volume of data in a secure environment, and
involving the pharmacists in event prevention. The Adverse
the breadth of analysis and ad hoc reporting available to the
Drug Event Monitor won the Institute for Safe Medication
site manager [31].
Practices Cheers Award in 2002 for its excellence in proac-
Our main criteria for application selection are security,
tively identifying potential adverse drug events. These kinds
ease of use, and speed, since these are major barriers to
of proactive monitoring will eventually be used at other insti-
staff reporting. We are evaluating the breadth of scope of
tutions within the network to supplement spontaneous
the product (Does it include near misses? Does it include
reporting.
ambulatory care? Does it have detailed modules for more
than just medications and slips/falls?). In addition, we are
evaluating the coding taxonomy to make sure it would col-
Process measurement: future initiatives
lect enough systems-related information. We require a fol-
low-up module where the appropriate leaders could edit/ Vital components of safety measurement include ascertain-
modify the report once follow-up was complete. We ing provider willingness to report problems and conducting
require an ability to integrate into our network e-mail sys- audits looking for adverse events and near misses. Surveying
tem so that appropriate leadership would get e-mail notiWca- provider attitude and tracking the use of spontaneous
tion of the Wling of the report. We are looking at the reporting systems will elucidate whether willingness to
system’s capacity to generate reports or export data into report events improves. Web-based reporting systems will
databases for our own report generation. Finally, adequate improve our ability to evaluate both of these. Adverse
customer support is essential. A system is currently in a events and near misses can be monitored in many ways. For
pilot phase and nursing staff have been very pleased with example, in one of our hospitals, pharmacy interventions are
the speed and ease of use. We have seen increases in report- used to identify areas of knowledge deWciency on the part of
ing in the pilot areas, particularly in areas that had house staff, and a medication competency exam has been
extremely low reporting rates previously. In addition, we developed based on these interventions. The exam is given
have seen increases in reports from physicians, which we to incoming interns and then again as their internship ends.
attribute to the speed of the system. The exam results are monitored to evaluate how effective
The Patient Safety Leaders Group is given regular pharmacy education has been during the year. The compe-
updates on experience with the pilot and the impact of this tency exam is modiWed each year based on the previous
on a plan for larger rollout. The ultimate goal is for all the year’s pharmacy interventions.
Partners institutions to use this common reporting system As noted earlier, another hospital has implemented a com-
so that hospitals can then share information about certain puterized monitoring program in which an event monitor
common event types and learn from each other about screens the computerized database and sends alerts daily to
systems improvements. Issues such as medication errors and pharmacists who can then review them and make interven-
adverse drug events can be discussed using common termi- tions. This generic approach will likely eventually be suitable
nology, and rare but serious events can be measured jointly so for screening other sources (such as discharge summaries) for
that hospitals can learn from the experiences of others. adverse events [38].

i37

A. Frankel et al.

Conclusions and the Institute for Safe Medication Practices for executive
level and middle management patient-safety positions. These
As the concepts underlying patient safety mature, it is becom- positions must be empowered to integrate safety, quality, and
ing possible to develop a cohesive and broad patient-safety risk management departments, and to base actions on promot-
strategy. We have described the path we have taken, although ing transparency and open communication [39,40].
other alternatives might have been chosen, and in addition to In conclusion, developing and implementing a strategy for
the efforts described, each hospital has numerous individual improving patient safety within this large, loosely integrated
projects underway. A broad patient-safety strategy may be delivery system has been challenging but exciting. Initial
divided into three categories: cultural change, core process efforts have focused on cultural change, process change, and
change, and process measurement. Our initial efforts across process measurement, and many other projects in these areas
the Partners integrated health care system include initiatives are being evaluated and considered for pilot testing. Clearly,
in each of these areas. We have many additional projects that there is no right answer as to which projects an integrated
we are considering in each category, including both technology- delivery system or hospital should undertake, and there are
related and non-technology-related interventions. numerous possibilities from which to choose. Some of the
strategies involve technology but many do not. Decisions
need to be based on measured need, leadership support, inter-
Conceptual models for the future est, and resources. However, we feel that an emphasis on
culture, process, and measurement makes the most sense

Theoretical concepts determined the initial framework for for both short-term and long-term safety improvements.
our patient safety strategy. Further construction was based on
hospital interests and the efforts of those invested in each
project. Two years later, collaborative efforts by all have Acknowledgements
helped reWne patient safety theory. Hospitals and integrated
delivery systems just beginning to formulate a patient safety We acknowledge support from Partners HealthCare (see
plan can build on work done and may develop a more solid page i40).
framework for themselves. While still mostly theoretical and
unproven, safety in overview is becoming clearer and should
include the following: (i) leadership promotes patient safety as References
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