In October 2007, Beth Israel Deaconess Medical Center in Boston set the goal of eliminating all preventable harm. The hospital's board and quality leaders had went on a quality- and patient safety-focused retreat that included field observation of practices in the hospital. As a result of this retreat, the board decided to make quality and safety a strategic priority for the hospital, and eliminating preventable harm became the focus of the organization.
The concept of preventability
While the goal of eliminating preventable harm is admirable, it raised questions of how to define preventable harm. Initially, skeptics thought BIDMC would take advantage of the vagueness of "preventability" to avoid taking responsibility for adverse events. However, BIDMC's definition of preventability actually encouraged accountability, according to Kenneth Sands, MD MPH, senior vice president of health care quality at BIDMC. "In reality, it has caused us to look at the causes of harm and work very hard to say, 'What are we doing in every case to try and make each case preventable?'"
Defining harm
BIDMC decided to use the National Coordinating Council for Medication Error Reporting and Prevention index to define harm. The NCC-MERP scale assigns a letter from A to I to describe different severities of harm, where A is an event that had the potential to cause error and I is an error that may have contributed to or caused the patient's death. BIDMC chose to focus on preventing events assigned an F — "an error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization." Some examples of preventable harm include hospital-acquired surgical site infections, hospital-acquired ventilator-associated pneumonia and acquired pressure ulcers.
Dr. Sands says BIDMC chose this level of harm because focusing on more serious events has the potential to yield the greatest benefit in terms of patient safety and quality.
Defining preventability
The hospital then created a two-step definition of preventability. "Since there was nothing in the literature that defined preventability, we had to come up with our own definition," Dr. Sands says. In the first step, the hospital determines if all the hospital's protocols regarding the event were followed. For example, if a patient fall resulted in injury, BIDMC would assess whether providers identified the patient as at risk for a fall on the patient's chart, made a call light available to the patient, managed the patient's medications appropriately and followed other fall-related hospital standards. If any of these standards were not followed, the fall was deemed preventable.
If these standards were followed, the hospital then moves to the second step and determines if any reasonable change in the hospital's protocol could have prevented the injury. Interdisciplinary teams go through a rigorous process to identify any intervention the hospital could have taken to prevent the event. If they do identify such an intervention, the event is considered preventable even if the hospital's standards were followed correctly.
For example, BIDMC had a case of a patient fall resulting in harm although the providers followed all the hospital's standards for falls prevention. After analyzing the event, an interdisciplinary team identified the main cause of the fall as the patient's failure to acknowledge his or her risk for falling and ask for assistance. A BIDMC nurse had a similar experience when she was a patient in the same unit — she did not consider herself at risk for falling but she did fall, according to Dr. Sands.
The hospital created a pamphlet for patients that explains the nurse's experience and her understanding of patients' feelings as well as the importance of asking for help. This pamphlet has become a new standard for BIDMC falls prevention. "I don't think we would have gotten to that level of commitment to trying to find an answer unless we had that two-step definition process," Dr. Sands says.
As shown in this example, BIDMC's definition of what is preventable can change over time depending on findings of new prevention measures. "If a new way to prevent ventilator-associated pneumonia appears in the literature tomorrow, then what was yesterday's non-preventable ventilator pneumonia may be tomorrow's preventable ventilator pneumonia," Dr. Sands says.
Fostering creative solutions in interdisciplinary teams
One way BIDMC ensures an exhaustive review of potential changes that would make harm preventable is by creating interdisciplinary teams. For example, if an adverse event occurred in the surgery department, other service lines, such as radiology, would become involved to help determine the event's preventability. These interdisciplinary teams meet twice monthly to discuss causes of harm and may have additional meetings to address a specific type of harm, such as bloodstream infections. This model "leads to very creative conversations about whether we can do things differently to make things safer," Dr. Sands says. "We find that that interdisciplinary input can often lead to new ways of thinking about ways to prevent harm."
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The concept of preventability
While the goal of eliminating preventable harm is admirable, it raised questions of how to define preventable harm. Initially, skeptics thought BIDMC would take advantage of the vagueness of "preventability" to avoid taking responsibility for adverse events. However, BIDMC's definition of preventability actually encouraged accountability, according to Kenneth Sands, MD MPH, senior vice president of health care quality at BIDMC. "In reality, it has caused us to look at the causes of harm and work very hard to say, 'What are we doing in every case to try and make each case preventable?'"
Defining harm
BIDMC decided to use the National Coordinating Council for Medication Error Reporting and Prevention index to define harm. The NCC-MERP scale assigns a letter from A to I to describe different severities of harm, where A is an event that had the potential to cause error and I is an error that may have contributed to or caused the patient's death. BIDMC chose to focus on preventing events assigned an F — "an error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization." Some examples of preventable harm include hospital-acquired surgical site infections, hospital-acquired ventilator-associated pneumonia and acquired pressure ulcers.
Dr. Sands says BIDMC chose this level of harm because focusing on more serious events has the potential to yield the greatest benefit in terms of patient safety and quality.
Defining preventability
The hospital then created a two-step definition of preventability. "Since there was nothing in the literature that defined preventability, we had to come up with our own definition," Dr. Sands says. In the first step, the hospital determines if all the hospital's protocols regarding the event were followed. For example, if a patient fall resulted in injury, BIDMC would assess whether providers identified the patient as at risk for a fall on the patient's chart, made a call light available to the patient, managed the patient's medications appropriately and followed other fall-related hospital standards. If any of these standards were not followed, the fall was deemed preventable.
If these standards were followed, the hospital then moves to the second step and determines if any reasonable change in the hospital's protocol could have prevented the injury. Interdisciplinary teams go through a rigorous process to identify any intervention the hospital could have taken to prevent the event. If they do identify such an intervention, the event is considered preventable even if the hospital's standards were followed correctly.
For example, BIDMC had a case of a patient fall resulting in harm although the providers followed all the hospital's standards for falls prevention. After analyzing the event, an interdisciplinary team identified the main cause of the fall as the patient's failure to acknowledge his or her risk for falling and ask for assistance. A BIDMC nurse had a similar experience when she was a patient in the same unit — she did not consider herself at risk for falling but she did fall, according to Dr. Sands.
The hospital created a pamphlet for patients that explains the nurse's experience and her understanding of patients' feelings as well as the importance of asking for help. This pamphlet has become a new standard for BIDMC falls prevention. "I don't think we would have gotten to that level of commitment to trying to find an answer unless we had that two-step definition process," Dr. Sands says.
As shown in this example, BIDMC's definition of what is preventable can change over time depending on findings of new prevention measures. "If a new way to prevent ventilator-associated pneumonia appears in the literature tomorrow, then what was yesterday's non-preventable ventilator pneumonia may be tomorrow's preventable ventilator pneumonia," Dr. Sands says.
Fostering creative solutions in interdisciplinary teams
One way BIDMC ensures an exhaustive review of potential changes that would make harm preventable is by creating interdisciplinary teams. For example, if an adverse event occurred in the surgery department, other service lines, such as radiology, would become involved to help determine the event's preventability. These interdisciplinary teams meet twice monthly to discuss causes of harm and may have additional meetings to address a specific type of harm, such as bloodstream infections. This model "leads to very creative conversations about whether we can do things differently to make things safer," Dr. Sands says. "We find that that interdisciplinary input can often lead to new ways of thinking about ways to prevent harm."
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