making major strides - university of...
TRANSCRIPT
Making Major Strides in Improving Patient Safety Physicians and scientists, especially at academic medi
cal cemers, have made dramalic strides in treating and
preventing disease. However, patiem safery in the U.S.
continues to be jeopardized by medical errors thar can
lead to death or severe inj ury to as many as 100,000
pari nts annually-not to mention "near misses" in
which tragic consequences are narrowly avoided.
At the University of Miami Miller School of Mcdicine
Jackson Memorial Hospital Center for Patient afery
(CPS), we provide a comprehensive approach to pre
venting medical errors and improving patient safety.
OUR MISSION IS TO BUILD SAFER HEALTHCARE BY:
• Harnessing t he power
of simulat ion t o enhance
medical educati on and
prevent pat ient harm
• Discovering pathways
t o ensure patient sa fety
through innovative research
• Becoming a lead ing resource
for designing safer hospitals
and hea lthcare facilities
AComprehensive Approach to Meet a Complex Challenge
lomenrary misjlldgm ents, uncl ea r orders. and
avoidable i nfe cl ions all represent medical errors
that can compromise pa tient sa~ ly.
To effective! address these complex challenges,
the UM-JMH Cemcr for Parient S,lfclY wo rb
to impro e p:ltiem safery in the fo llowing areas
of vulnerability:
• Bedside procedures • om[11\ll1ication .1nd reamwor
• Crisis managemem • Safe use of diagnostit: and (hemp 'u tic
technologies
• Hand hygiene
• Order writ ing • Pa tient confidentialiry
r hesc srraregi s to protect p:llicnL~ have also
been succes -ful ly incorporated inco cd ationa l
programs ~ r practicing prore~s i mals r:1l)ging (rom
ill - h o~pi lal lcams and emergency responders to
ph,trmacisls and risk managers .
CPS progra ms have been integrated in to the
training of phYSicians and nurses in almost all
Debr ipilng sessions, iI k Y omponent of ol lT1Ulillion education, allow trainees lo reflect on,s are, and learn from their experiences.
spt::cialties, incl uding anesthesiology, cmt'fgt::ncy
meuicine, intern,ll medicrnc. military medicine,
rilic.]1 care, ohstct rics and gynecology, fort::n~iL
scicl ceo and pediatrics.
CPS coIlahnr:nes with qllaliry. r i ~k t1Ianagement,
anJ 'ducational team ' throughout the Ulllv{'rsily
of Miami and Jackson Health Systcm~ . As Il t::w
cbllcngcs are iJenuf1eJ, we.: work to find solurions
leading to cont in ued improvement in the care an d
safery of r,1tie nl~ .
Maximizing the Potential of Simulation-Based Education
T he cornerstone of the UM-JM11 Cen ter for
Patient Safety curr iculum is simulation-based
ducatiol1-a powerfu l ap proach that allows
trainees to r<.::st and hone their abilities in scenarios
that range fro m ro utine exams to medical
el 1 rgencies . ore than 20 CPS train ing programs
blend simula tion wi th didactic education , case
review and discussion, standa rdized patients, and
othcr lechniq u s and tools thJr reinft rce key
concepts while strengthening skills.
1 he center's 8,OOO-square- foo t facility comp rises
mo re than 2,000 quare feet of spacc d dicated to
simula tion-based traini ng aCli\'itit;:s and rest:arcrl.
Simulatio n labs replicate parient ca r st:tting'
such as an operaring
room, em~rgency roOtl1.
intensive care unir ,
radiology su ite, hosp ita l
patient roo m, cardiac
cHheteri/Jtion lab, and
amhularory cl inic.
W ithin o ur simulation fac il ities, as m any as six
pa ti ent simul. r"ors can be used simul taneously.
A nursing trainee gains hJnds-o~ experience in critical care Wi th a l1igl -fidelity ~imu la tor.
The sim lll· ro rs may be conrroUed from the
bedside Fo r info rm I teaching or Irom the
center's control room for full -scale, team-hased
. im ulations . The comrol roo m also includes
ideo and aud io production <.::quip mcnl and
softwJre to create materia ls for off-site learni ng.
O ur ex p n use of these technologies enmrcs that
the educatio nal potencia l of everyone of OlJr
traini ng aeri 'ities is uti lized ro the fullest.
Implementing Insights at Every Stage of Care
The UM-JMH Cenrer ror Patienr Safery add r ses
pat ient sa rery issues through a varicry of proj cccs
nlJ1 ded by both governmen tal agencies on dle
state and federa l levels and by private sources.
IT ey areas include:
Hospital redesign: According to the InslirlJ[e of
Medicine. Haws in the layout of hea lthcarc cil ities
comribure 10 mt:dical errors. CPS uses unique
si mulation rne l horl~ ro cvaIUlI[t: des igm fo r satery
rea tures prior co construction or renovatio n.
Hospital-acquired infection (HAl): Hand hygiene is
the single most effeetive measure for red ucing
hospi Lal -acquired
infcLl ions, which I ill
thousands of p;ltients
c;lch year. The hand
hygiene program
developed by the
cenrer includes an
educational. fil m, slide presentations, ski lls (esLing.
and l on~-lerm monitOri ng. T he cene r has als cre
atcd a Web-hased e-lea n i ng program to help d is
seminate hand hygiene awareness and skills.
A key target at patien t ~afety training i, inlectlons caused by biJctert ii hat may be transmitted (dbove) ill vanoll '; sfte~ in <'l hospital room or (left) on con tamillated !lands
Reporting near misses: Narrowl ! Jvoided medical
errors can provide extremely useful clues co
improving hea lthcarc rraining and pracuee. The
center is developtng volu ntary. Web-based data
collection and analys i, tools to gather and evaluare
near misses in hospi tals aud ,urgical ,In ri birthing
cenrers throughout Flot·ida.
Expert Leadership to Advance the Field
David]. Bim bach, MD ., M.r~H ., direcror of the
Center for Parienc Safety, bri ll a wealm of knowledge
and expertise to the field of patienc safety. O ur team
includ s physicians, nurses, a simulation engineer, and
administrative suppon staff. Instructors from every
clinical depanmem on campus collaborate wim LIS to
develop specialry- pecific training programs.
[n add ition, the cem er nas a video production
expert on staff, enabling o ur team to create
training ideas dramatizing medical scenarios.
CPS faculry and staff also work closely with experts
at schools and colleges within the niversity of M iami
as well as with other academic institutions. Our
relationship' v itl l Professor Eduardo Salas, Ph. D .,
a world-renowned teamwork expert at the University
of Cenrral florida in O rlando, and Captain W dliam
Rutherford, M .D ., a United Airlines simulation e pert
who now teaches at Western Michigan Universiry, have
produced several highly-productive, ongoing colhbora
tions. In addition, Paul C luck, M.D., the past chair of rhe
acional Patient Safery Foundation Board of Dircccors,
ha, recently joined d1e Center for Pariem Safery team
and will enh<wce our narional and international efforts.
Led by DaVid J Birnbach, M D , M PH {above left}, the CPS team includes (above right) assoc.iate director Joshua Lenmus, D O , R.Ph., FA C.P (Below) key strategy utilized by CPS to minimize medical errors is root c use analysis, here bemg taught to medical residents at Jackson Memortal Hospital .
.1Health UNVERSITV Of MIAMI HEAlTH SYSTEM
MILLER SCHOOL OF MEDICJNE
UNIVERSITY OF MIAMl
Jackson HEALTH ~Y~TF.M