Illinois Medicine

patient safety by Kevin McKeough BETTER SAFE–AND SORRY The Institute for Patient Safety Excellence sets the pace N 34 | SUMMER 2 011 in preventing and acknowledging medical errors, from rigorous reporting protocols to a new lipid emulsion technique ATIONALLY RECOGNIZED AS A LEADER in pa- tient safety, the University of Illinois at Chicago's Institute for Patient Safety Excellence recently received two major grants to educate other hospitals in techniques pioneered by its faculty. A $3 million federal grant is making it possible for IPSE to test at nine other Chicago hospitals the effects of its pioneering approach to acknowledging and addressing medical errors. Another grant is en- abling faculty members to disseminate an innova- tive method to treat cardiac arrest and other adverse reactions to local anesthetics and other medications. Patient safety emerged as a major concern thanks in signifi- cant measure to a 1999 report by the Institute of Medicine, a part of the National Academy of Sciences, which found that at least 100,000 patients die each year from preventable medical errors. "That's the equivalent of a Boeing 747 going down every single day," says Tim McDonald, MD, JD, IPSE co-director, professor of an- esthesiology and pediatrics, and chief safety and risk officer for health affairs for the University of Illinois. Despite increased attention to patient safety since the 1999 report, the overall situation hasn't necessarily improved much. Last year, the New England Journal of Medicine published the results of a study conducted in 10 North Carolina hospitals from 2002 to 2007 that found the rate of medical errors remained stagnant during that time. It's been a different story at Illinois Medicine, thanks in large part to IPSE, founded in 2004 with a mission to improve patient safety through education, research and clinical care and to create an interdisci- plinary culture of patient safety within University of Illinois at Chicago's six health science colleges, the University of Illinois Medical Center and other health care institutions. The institute has received national recognition for pioneering a seven-step approach for acknowledging and addressing medical er- rors, known as the Seven Pillars: reporting the event; investigation and analysis of how the event occurred; communication and disclosure to the patient and/or the patient's family; apology and remediation; patient safety and systems improvements; data tracking and performance evalua- tion; and staff education and training. The Seven Pillars program's success at the medical center led to the $3 million grant from the Agency for Healthcare Research and Qual- ity in the U.S. Department of Health and Human Services to test this approach. After the nine participating Chicago hospitals implement the program, the study will compare their liability costs, claims data and im- provements in quality of care over a three-year period to those of other hospitals that do not take this approach. "While it is generally accepted that full disclosure benefits pa- tients, families and health care providers and systems, the widespread adoption of full disclosure has yet to occur," McDonald says. "Many in

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