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Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Ten Case Studies

Executive Summary

In 1999, the Institute of Medicine (IOM) shocked the nation with its estimate that 48,000 to 98,000 Americans die each year in the hospital—not from the illnesses or injuries for which they sought treatment, but because of mistakes and oversights in medical care. Although the numbers cited by the IOM were eye catching, the statistics were compelling because they captured a troubling idea: people can be harmed by care meant to help them.

The title of the IOM's report, To Err Is Human: Building a Safer Health Care System, emphasizes the fact that humans are prone to error. Therefore, the report contends, keeping patients safe from harm cannot depend on human perfection. Industries such as aviation and nuclear power achieve highly safe operations by taking human fallibility into account when people are trained, systems are designed, and organizations are managed.

The IOM report raised public and professional awareness of the need for change and galvanized positive action from many parts of the health care system. Before its publication, experts and leaders were working to educate others about the problem and to discover and demonstrate practical means for improvement. In more recent years, these efforts have intensified and more organizations and individuals have joined the cause. Nevertheless, experts agree that far more needs to be done to realize the vision of the IOM report.

This report, commissioned on the fifth anniversary of To Err Is Human, illustrates innovations in five areas that hold great promise for improving patient safety if applied nationally:

  • promoting an organizational culture of safety,
  • improving teamwork and communication to promote patient safety,
  • enhancing rapid response to prevent heart attacks and other crises in the hospital,
  • preventing health care-associated infections in the intensive care unit, and
  • preventing adverse drug events throughout the hospital.

Using 10 case studies, this report describes the actions taken and lessons learned from organizations, teams, and collaborations, with suggestions for those seeking to replicate these successes. The organizations studied range from large integrated delivery systems to small community hospitals. Some have been recognized as leaders, while others are lesser-known innovators. Likewise, some of these efforts are now mature, while others are showing great promise. Overall, the cases demonstrate that improvement can occur in any organization where there is leadership, purposeful application of methods, and the will to change for the sake of patient safety.

One overriding lesson emerges: the programs identified organizational cultural change—the creation of a "patient safety culture"—as the critical element in making patients safer. Organizations seemed to differ chiefly in the methods used to instill a safety culture. The first two case studies examine organizations that have undertaken wide-ranging organizational change strategies, while the others describe more specific approaches. Regardless of method, the goal is a safety culture that promotes continuing innovation and improvement.

The organizations and teams studied for this paper have reported impressive improvements in patient safety and related organizational performance, including:

  • substantial reductions in observed adverse events and certain hospital-acquired infections;
  • apparent elimination of serious errors such as reported wrong-site surgeries;
  • reduction in death rates;
  • improvement in safety attitudes, teamwork, and communications behaviors associated with improved safety performance;
  • increased reporting of safety incidents and more effective investigations into their causes, leading to more useful recommendations for changes to prevent recurrence;
  • enhanced nursing morale and decreased nursing turnover and vacancies;
  • more efficient use of staff time by eliminating repeated work and delays; and
  • cost-savings resulting from shorter hospital stays.

Many of the cases demonstrate a correlation between patient safety and other domains of quality improvement. For example, collaborative rounds improved awareness of safety issues as well as patient- and family-centeredness of care and clinical outcomes. Interventions to improve safety through teamwork and communication improved staff morale and reduced nursing turnover. Empowering staff with improvement tools and knowledge is likely to have spillover effects on other domains of quality. The individuals, teams, and organizations studied were frequently engaged in other types of quality improvement activities or were considering ways to apply their learning to additional areas. These signs of collateral benefits and connections suggest that patient safety should not be approached as an isolated domain of quality.

The organizations profiled here would readily admit to being on only the first leg of the journey. Much more work is needed to achieve a truly safe environment for patients. These experiences, therefore, should be seen as a source of inspiration and encouragement to achieving even higher levels of performance. Although the cases focused on hospital settings, the lessons learned here are potentially applicable to ambulatory care environments, where patients receive most of their health care.

Table ES-1. Summary of Case Study Sites, Interventions, and Results

OrganizationSettingInterventionSelected Results
Sentara Norfolk General Hospital, Norfolk, Va.A 569-bed, level 1 trauma center; one of six hospitals operated by Sentara Healthcare, a regional integrated health care delivery networkAccelerate patient safety improvement through a multifaceted culture change program involving setting and monitoring behavioral expectations, enhancing analytic capabilities, and streamlining and focusing on critical policies
  • 42% increase in expected communications behaviors
  • 50% reduction in events of harm per 10,000 adjusted patient days when culture change strategies were applied system-wide
U.S. Dept. of Veterans Affairs, National Center of Patient Safety, Ann Arbor, Mich.An integrated health care system that serves 5.1 million veterans and 7.6 million enrollees at more that 1,300 sites nationwideLead organizational cultural change by empowering local facilities and frontline staff with proven tools, methods, and initiatives for patient safety improvement
  • 30-fold increase in internal safety incident reporting
  • 100% increase in perceived preventability of safety events studied by root cause analysis teams
Kaiser Permanente, Orange County, Calif., and Northern California regionLocal medical centers of an integrated group-model health maintenance organization with 8.2 million people enrolled nationallyInitiate a preoperative safety briefing and a perinatal patient safety project as part of a program of organizational learning to promote effective teamwork and communication in high-risk areas
  • A near doubling in the proportion of operating room staff reporting positive teamwork climate
  • Two-thirds reduction in the turnover rate among operating room nursing staff
Concord Hospital, Concord, N.H.A 295-bed community hospital that annually treats 250 patients in its cardiac surgery programUse collaborative rounds involving all members of the care team with the patient and patient's family to proactively identity and prevent potential errors and safety threats
  • 56% lower than expected risk-adjusted mortality among cardiac surgery patients
  • 15% to 32% higher staff ratings of teamwork and work satisfaction compared to traditional rounds
Missouri Baptist Medical Center, St. Louis, Mo.A 489-bed acute care hosptial within BJC HealthCare, a health system comprising 13 hospitals and other facilitiesEstablish a rapid response team to intervene early with patients showing signs of medical deterioration before the suffer acute crises
  • 60% decrease in emergency calls for respiratory arrest
  • 15% decline in cardiac arrests
  • 3.95% reduction in hospital mortality rate
Johns Hopkins Hospital, Baltimore, Md.A 14-bed oncology surgical ICU and a 15-bed surgical ICU within a 900-bed academic medical center; one of three acute care hospitals in the Johns Hopkins Health SystemImplement a comprehensive unit-based safety program that empowers staff to identify and eliminate patient safety hazards following eight action steps
  • 49% to 91% increase in the proportion of ICU staff reporting positive safety climate
  • Elimination of 43 observed catheter-related bloodstream infections, saving eight lives
  • One-day reduction in average ICU length of stay, saving an estimated $2 million annually
VHA, Inc., Transformation of the Intensive Care Unit National CollaborativeMore than 40 ICUs in diverse community hospitals nationwide that are members of VHA, a health care cooperative serving not-for-profit health care organizationsFocus all members of the care team on adhering to a "bundle" of evidence-based care practices associated with improved patient outcomes
  • 29% to 41% reduction in combined rates of ventilator-associated pneumonias
  • 11% to 15% decrease in average lengths of stay across participating ICUs
  • 18% lower mortality
Allegheny General Hospital, Pittsburgh, Pa.A medical ICU and a cardiac care ICU in an 829-bed academic health center, part of six-hospital West Penn Allegheny Health SystemApply the Perfecting Patient Care approach, modeled on principles of the Toyota Production System, to specify best practices, eliminate variations from standards, and work toward ideal performance
  • 76% reduction in rate of central-line associated bloodstream infections, saving 18 lives per year
  • $2 million savings by reducing unreimbursed costs of care
Institute for Healthcare Improvement, Cambridge, Mass. and Premier, Inc., San Diego, Calif.A nonprofit organization that works with health care institutions worldwide to spread quality improvement, and an alliance of more than 200 not-for-profit hospitals and health systemsDevelop a simple trigger tool that organizations can use to measure the incidence and kinds of adverse events, so as to prioritize areas for improvement, design appropriate interventions, and track the effect of changes over time
  • 50-fold increase in detection of adverse drug events as compared to other common methodologies such as incident reports, pharmacy interventions, or billing codes
OSF St. Joseph Medical Center, Bloomington, Ill.A 165-bed acute care hospital, part of OSF HealthCare, a six-hospital integrated health care network based in Peoria, Ill.Reduce adverse drug events by improving the process of medication reconciliation, the safe use of high-risk medications, and the reliability of medication dispensing
  • 10-fold reduction in detected adverse drug events
  • 8% improvement in perceived safety culture among hospital staff
Note: ICU = intensive care unit.
Promoting High Reliability Surgery and Perinatal Care Through Improved Teamwork and Communication at Kaiser Permanente

Publication Details



D. McCarthy and D. Blumenthal, Committed to Safety: Ten Case Studies on Reducing Harm to Patients, The Commonwealth Fund, April 2006