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Project Title:
A systems approach for improving region wide patient safety
Funding Agency:
National Institutes of Health
Total Project Period:
Sep 26, 2001 - Aug 31, 2004
Principal Investigator:
Carl Sirio, MD
Co-Investigator(s):
Janice Pringle, Ph.D.; Robert Weber, Ph.D.; Carlene Muto, M.D.; Levent Kirschi;
Ph.D.; Edward Harrison, M.B.A.; Donna Keyser, Ph.D.; Shan Cretin, Ph.D.; Denise Rousseau, Ph.D.; Ranga Ramanujam, Ph.D.; Susan Skledar, Ph.D.
Project Summary:
Preventable adverse events, including nosocomial infections (NI) and medication errors (ME), are among the nations most pervasive patient safety problems. Establishing effective reporting systems capable of compiling credible data is a necessary but insufficient condition for creating the capacity for sustainable change. In 1997, the Pittsburgh Regional Healthcare Initiative (PRHI) was created, a collaboration of leaders from all major healthcare stakeholder groups in a 6 county metro region representing diverse patient populations. PRHI goals include achieving the world’s best patient outcomes by identifying and solving problems at the point of patient care including the elimination of NIs and MEs. Under PRHI, the regions 30 hospitals have instituted a close collaboration with the US Pharmacopeia (USP) and the Centers for Disease Control (CDC) to implement MedMARxO and components of the National Nosocomial Infection Surveillance System (NNIS). All healthcare facilities participating in this research demonstration have agreed to share their data locally, thus providing an important opportunity for cross-organizational comparisons. Based on shared analysis of regional outcomes data, prevention strategies and interventions are being developed for both nosocomial infections and medication errors. These will be implemented through a variety of mechanisms including PRHI’s existing Center for Shared Learning. Error reduction in organizations involves exploration and evaluation of multiple interrelated systems. Using multiple metrics described herein we have three sets of study aims: 1) To understand how well the Reporting Systems associated with NIs and MEs succeed in creating usable information. 2) To understand how well the Feedback Review Systems function. 3) To understand the Problem-Solving Systems through which knowledge is translated into organizational learning. Taken together, these systems inform and shape the conventional learning model: Data = Information = Knowledge = Learning. In order to accomplish this evaluation, we will establish and operate an investigative Data Coordinating Center. Our assessment of this unique collaboration may provide a generalizable model for regional, systems based approaches to patient safety.
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