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Advancing Patient Safety

Developing an improved understanding of failures that threaten patient safety and implementing measures to reduce patient risk are major goals for PNNL. In response to a recent standard from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), more than 18,000 accredited health care organizations in the United States and Canada are performing analyses and developing ways to prevent errors that could threaten patient safety. Hospitals, health care networks, health maintenance organizations, integrated delivery networks, preferred provider organizations, clinical laboratories as well as home care, assisted living, behavioral health care and ambulatory care organizations are among the organizations that will conduct these assessments. “JCAHO encourages members to consider engineering analysis practices used successfully in other industries to evaluate failures and correct mistakes,” said PNNL's Jon Young, Program Manager.

In 1999, the Institute of Medicine reported that about 98,000 deaths occur annually due to health care failure. It is important for the industry to lower these statistics. Hospitals are for healing. With the help of tools used in the nuclear, aerospace and chemical industries, researchers at PNNL are helping make sure they stay that way. PNNL researchers are working with three hospitals in Washington State to meet the new standard. “The first step is identifying situations where errors have occurred that could have, or did, result in serious consequences,” said Garill Coles, Chief Engineer. “We then proactively apply engineering analyses to develop step-by-step scenarios that pinpoint vulnerable areas and identify where new measures are needed to avoid placing patients at risk.” PNNL researchers have experience analyzing difficult and high-stress situations where mistakes are most likely to occur from previous work with the nuclear industry and NASA. The ultimate goal for NASA, as it is for the health care industry, is to preserve human life.

In another approach to patient safety, PNNL is applying powerful techniques to analyze and visualize data in pilot studies with U.S. Pharmacopia, an organization that collects data on medication errors from hospitals nationwide, and Johns Hopkins Hospital, that collects Intensive Care Unit incident data. "We're using our data mining and data visualization technologies to analyze incident data and put them into a risk context," Young said. "This is an exciting opportunity to refine the understanding of errors because, in the case of medication, we'll have hundreds of thousands of records on medication errors," Young said. Eventually, study results may be published in reports and go back to hospitals.

"We have other powerful risk analysis technologies we hope to apply in the future. This is just a starting point," Young said of PNNL's work with risk assessment at hospitals. Ultimately, analysts hope to apply risk analysis and data visualization techniques to help hospitals rank problems and determine which issues they'll address first and how. Using risk assessment techniques to evaluate safety is not new to PNNL analysts, who have employed these techniques successfully in the nuclear, aerospace and chemical industries.

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