Patient Safety Made Simple

Some ideas are so simple yet so brilliant that your reaction is “why didn’t I think of that!” When my dad experienced such a moment, he would say, “That’s a very pregnant idea!” meaning it was wonderful and filled with unlimited possibilities to solve a problem. 

I heard my dad’s voice in my head this week when I read two new studies on patient safety, one in JAMA Open Network and the other in the New England Journal of Medicine.  Together, the two studies remind us that making care safer and more effective for patients isn’t as complicated or daunting as it seems.

In the first study, published Nov. 11 in JAMA Open Network, 11 researchers from such lofty hospitals and universities like Brigham and Women’s Hospital, Rhode Island Hospital, New York-Presbyterian Hospital, Brown, Harvard, and Vanderbilt figured out that putting a patient’s photo in the patient’s medical record made it far less likely that the patient would undergo a diagnostic test ordered for someone else.

You can download the JAMA study here. 

The researchers studied more than 2.5 million tests ordered for nearly 72,000 patients over a two-year period at an academic medical center in Boston. (I’m assuming it was Brigham and Women’s Hospital.) They compared the rate of “wrong-patient order entry,” or WPOE for patients who had their photos in their medical records with patients who didn’t have their photos in their medical records. WPOEs are orders placed by clinicians for the wrong patient. 

The WPOE rate for the 60,849 patients who didn’t have their photo in their medical record was 186 per 100,000 orders. The WPOE rate for the 19,091 patients who let the hospital take their picture and put it in their medical record was 133 per 100,000 orders, more than 28 percent lower.

“Unlike prior interventions, this solution required no added practitioner time burden or risk of alert fatigue,” the researchers said.

A picture is worth a thousand lives. 

In the second study, published Nov. 12 in the NEJM, six researchers from Kaiser Permanente figured out that if you keep a closer eye on patients’ vital signs in the hospital, you’ll know when they’re about to go downhill so you can intervene faster and prevent more of them from dying.     

You can download the NEJM study here. 

The researchers studied a clinical decision support tool that uses data from a non-ICU patient’s medical record to calculate the patient’s clinical deterioration risk while in the hospital. The tool then monitors changes in the patient’s data to predict that the patient will take a turn for the worse in 12 hours.

But rather than sounding the 12-hour alarm bell with doctors and nurses on the floor, the system sends the alerts to specially trained nurses who remotely monitoring the system for alerts. The nurses, in turn, dispatch a rapid-respond team to the patient to intervene and ideally stop the slide before it starts.

Kaiser installed the system at 19 hospitals over a nearly four-year period ending in early 2019.

The researchers compared the 30-day mortality rates of 13,274 patients whose medical status triggered alerts during their stays with those of 23,797 patients whose medical status would have triggered alerts if the system had been in place at their hospitals. 

It was no contest, unfortunately for the control group.  

When the specially trained nurses remotely monitored changes in the data, 15.8 percent of the patients died. When someone else or no one monitored changes in the data, 20.4 percent of the patients died. That’s a nearly 30 percent jump in the 30-day mortality rate. 

A watched patient never boils?

Like we say here at 4sight Health, outcomes matter. And as these two new studies point out, it just takes some simple, creative or even staring-you-right-in-the-face ideas to improve outcomes for patients.  

Not only did I hear my dad say, “Those are very pregnant ideas!” He also said, “See, you could have been a doctor.” 

Thanks for reading.

Stay home. Stay safe. Stay alive.