Illinois Medicine

the medical-legal and medical liability arenas still contend that admit- ting mistakes and making swift restitution following a patient safety incident will inflate costs, open oneself up to liability and astronomi- cally increase an institution's risk and resulting costs." But the University of Illinois Medical Center has seen its medical liability decrease in the three years since the Seven Pillars approach was put into place. That's because the process not only addresses the needs of pa- tients and families after an incident, but it also instills a commitment to analysis and subsequent process improvements to reduce future adverse outcomes, says David Mayer '78, MD '82, IPSE co-director, associate professor of clinical anesthesiology and associate medical director for patient safety graduate medical education. "Thanks to these improve- ments, the medical center's malpractice costs actually have gone down even as caregivers and hospital leadership have been more forthcoming about errors," he says. In addition, the medical center also encourages staff to report er- rors and unsafe situations, honoring them in the hospital newsletter and giving them performance rewards. "Those people are celebrated, as op- posed to other places where they get ridiculed or shamed," McDonald says. "Every report is a gift, because when we identify something unsafe we can act on it and get better." anesthetics, tend to bind to lipids, and when too much anesthetic gets into the bloodstream or vital organs, "lipids have been shown to pull the drug out of the tissues, which can allow the vital organs to return to normal function." Mild adverse reactions to local anesthetics affect one in about every 1,000 patients and cause serious cardiac or neurological dysfunction in about one in every 5,000. The grant has funded an educational tool kit that includes a video and a PowerPoint presentation that hospitals can use to educate their caregivers about lipid resuscitation. Weinberg and Mayer, along with Leelach Rothschild-Dekoven, MD '03, Res '08, assistant professor of clinical anes- thesiology, also have begun collaborating with other Chicago academic medical centers on a project to conduct workshops on lipid rescue in each of the more than 80 hospitals in the greater Chicago area. "We hope it will become standard practice at all facilities where local anesthetics are given," Mayer says. "To successfully reduce medical errors A and improve patient safety, health care orga- nizations must reach the tipping point where adoption and application of a culture of safety becomes embedded throughout their institu- tion," he adds. "UIC has made that commit- ment, and we're continuing to align expertise and resources in research, education and clinical service to maximize the safety of our patients." NOTHER NATIONAL INITIATIVE IS BUILDING on the research of Guy L. Weinberg, MD, professor of anesthesiology, who has pioneered the use of intravenous lipid emulsion infusion to treat cardiac arrest and other adverse reactions to local anesthetics and other medications. Weinberg and Mayer received a large grant from the Anesthesia Patient Safety Foundation to educate other hospitals nationwide about this use of lipids. Mayer explains that some drugs, such as local T Soap Monitor Medical center hand hygiene system halts infections O FURTHER THE CAUSE of patient safety, the University of Illinois Medical Center has adopted an automated sen- sor system that will help ensure caregiv- ers have washed their hands adequately before entering patient rooms in the intensive care unit. According to the U.S. Centers for Disease Control, practicing proper hand hygiene is the best way to prevent the estimated 1.7 million infections that patients in U.S. hospitals contract each year. When caregivers wash their hands and place them under sensors located in or directly outside patient rooms, the sensors send a wireless message to badges worn by the caregivers. The sensors detect the sterilizing alcohol in the soap and hand hygiene foams and gels in use at the medical center. Each hand-washing station has its own unique signal and a five-minute time limit. A wireless monitor above each patient bed searches for the message as caregivers approach. If the signal isn't detected, the badge vibrates, reminding the wearer to wash. The bed monitor also sends a report about whether the caregiver's hands have been washed to the system database. Monitors have been installed in 22 patient rooms in the hospital's neurosurgical and medical- surgical intensive care units. Many different groups of caregivers, including physicians, nurses, respiratory therapists and dialysis technicians, will wear the badges. "This system gives us a way to remind health care workers to wash their hands and to monitor hand hygiene, which is at the crux of all infection control prevention," says James Cook, MD, Harry F. Dowling Professor and chief of infectious diseases. "Behavior is hard to change, but we want to provide the best care possible and provide patients with the benefits of the latest hand hygiene system." I L L INOI S MEDICINE | 35

• Cover