IN THE NEWS
FOCUS3/19/2009
NEWS RELEASE
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Contact: John R. Melleky, CFRE Executive Director |
(804) 565-6324 (office) (804) 690-2879 (cell) johnm@scahq.org www.scahqgive.org |
SOCIETY OF CARDIOVASCULAR ANESTHESIOLOGISTS FOUNDATION AND DR. PETER
PRONOVOST TO COLLABORATE
FOCUS
Initiative to reduce human error; initial sites chosen
April 22, 2009 – San Antonio, TX – At the 31st Annual Meeting of the Society of Cardiovascular Anesthesiologists, the Society of Cardiovascular Anesthesiologists Foundation and Peter Pronovost, M.D., PhD, Director of the Quality and Safety Research Group at the Johns Hopkins School of Medicine, formally announced that they have entered into a collaborative endeavor to reduce human error in the setting of cardiovascular anesthesia and surgery. The FOCUS project (Flawless Operative Cardiovascular Unified Systems), a multi-year, multi-center initiative, will examine the physical and cultural environment of the cardiac surgery operating rooms, and will seek to define processes by which the cardiovascular operative teams can reduce the occurrence of human error. The research will be based on the cockpit (or crew) resource management (CRM) model, implemented worldwide by the commercial aviation industry. The CRM model is based on the concepts that “although individuals may make mistakes, it is possible for teams to be flawless” (John Nance), and embraces a culture in which everyone involved in servicing, preparing, or flying an aircraft is granted responsibility for that aircraft’s safety. Checklists, guidelines and standardization are tools used to ensure flawless team operation. Although every individual involved in cardiovascular operative patient care is dedicated to patient safety, the processes and communication patterns that exist frequently are inadequate to achieve the goal of absolute patient safety.
Why this initiative? In 1999, the Institute of Medicine report, To Err is Human: Building a Safer Health System, estimated that 48,000-98,000 lives are lost every year in United Sates hospitals due to human error, and that number is almost certainly an under estimation of the extent of the problem. In aviation terms, that would mean the crash of a fully loaded Boeing 747 every other day for one year. The cascade of events that result in loss of a patient’s life are typically rooted in human error, and prior efforts to reducing human error have often focused on disciplinary action and/or even the shunning/dismissal of a highly trained physician or medical personnel. An elimination of the offending human does not reduce the risk of future human error by itself unless the physician has somehow been otherwise truly incompetent. Prevention of future human error cascades requires understanding the human factors that led to the human error and requires efforts to learn about the systems that allowed failure to occur.
What is involved? The first step in the FOCUS initiative will be in-depth observation of the physical, emotional and cultural environment in the cardiovascular operating rooms. Using a set of highly refined metric instruments, the research team led by Dr. Pronovost will gather data from which a set of checklists, guidelines, or interventions will be developed. These interventions will then be tested in a series of beta sites, refined as needed, and then introduced to the national community of cardiovascular operative personnel.
This initiative follows numerous others within the greater anesthesia community which have led to this specialty being recognized as being one of the safest in medicine. Five sites have been chosen for this initial series of observations with support from the following teams:
Anesthesiologist: Christopher Young, M.D.
Surgeon: Edward B. Savage, M.D.
Anesthesiologist: Marc Kanchuger, M.D.
Surgeon: Aubrey C. Galloway, M.D.
Medical
Anesthesiologist: Jake Abernathy, M.D.
Surgeon: Fred A. Crawford, Jr., M.D.
Anesthesiologist: Gary Kanter, M.D.
Surgeon: John A. Rosou, M.D.
Anesthesiologist: Nanette Schwann, M.D.
Surgeon: Gary Szydlowski, M.D.
Dr. Pronovost and his team’s proposal were selected by the FOCUS Steering Committee from a Request for Proposals sent to 60 institutions. Dr. Pronovost’s special interest is applying research methods that improve quality of health care and safety, especially in critical care settings such as ICUs and operating rooms. His expertise in this area has gained international attention, and Dr. Pronovost was awarded a MacArthur Genius Grant in 2008. On a national level, Dr. Pronovost is leading an effort to develop the idealized ICU design with the Institute for Healthcare Improvement and developing standards for ICU quality measures with the VHA. Dr. Pronovost is currently working with the Michigan Hospital Association to improve intensive care unit care throughout the state. He is an active member of the National Coalition on Health Care and the medical advisor for the Leapfrog Group for patient safety.
The SCA Foundation, founded in October of
2007, is the philanthropic arm of the
Society of Cardiovascular Anesthesiologists.
The Foundation promotes and supports excellence in the care of patients undergoing
cardiothoracic and vascular procedures through education and research.
The Society of Cardiovascular Anesthesiologists is an international organization of over 7,000 cardiac, thoracic, and vascular anesthesiologists that promotes excellence in clinical care, education, and research. Formed in 1977 to promote the specialty of cardiovascular anesthesia, it has grown rapidly with the growth of cardiac, vascular and thoracic surgery. Over the past 30 years, the SCA has led the way in the training and certification of intra-operative echocardiographers, development of credentials for cardiovascular anesthesiology training (fellowship), and has collaborated with the wider medical community in setting guidelines for patient care.