According to Davis, it was an example of how the safety program and a large-scale IT implementation coalesced in a way that benefitted both. “The two really dovetailed nicely together,” he says. “Having doctors, nurses and IT people all working through these things together makes a huge difference, rather than having a solution that's designed somewhere in IT world and then dropped into a clinical world.”

Case #2: The Blood Bank

According to Steve Mandell, senior director for Clinical Information Systems at John Hopkins Hospital, the Blood Bank is different from the other adopted units at Johns Hopkins for one very simple reason - there are no patients. Its function, he says, is to provide services to the departments that care directly for patients.

As the unit's adopted leader, Mandell, who previously served as a vice president of IT for the American Red Cross, says he focused on helping his staff identify where and how sentinel events can occur, and what actions can be taken to prevent them. Through regularly held discussions, Mandell says he learned of operational issues that “interfered with their sense of confidence in the way they're being taken care of.”

For example, the staff was using outdated computers. “The blood bank staff is highly dependent on knowing the operating room schedules, which are all electronic, so even though they were able to get to the schedule, they weren't receiving real-time notices that cases were delayed or cancelled,” he says.

With Mandell's help, the unit worked with the operating room on a system that would notify them if a case was delayed or cancelled, which resulted in improved workflow and decreased waste of perishable products.

The ordering of blood products brought up another issue. Certain cases required a specific amount of product that had been cross-matched by type and was readily available. Therefore, a system was deployed with order sets that enabled providers to specify exactly what they needed in terms of volume and severity. In addition, a Web viewer of the blood product inventory is being developed to keep providers informed on order status.

“Now, instead of getting calls all night long before the surgery as to whether or not the blood is ready, the providers will be able to use a Web interface that's linked to a system that they're familiar with,” Mandell says. This way, “They don't have to learn new log-ins, and they'll be able to see what's available, what products are in the manufacturing process and which events specifically detect a cross-match for their particular patient.” That, Mandell says, will hopefully improve the communication and reduce phone calls, giving staff “more time to do high quality work.”

Case #3: Wilmer Eye Institute

Ever since Mike McCarty, chief network officer at Johns Hopkins Hospital, first adopted the Wilmer Eye Institute three years ago, his leadership philosophy has focused on tackling safety and quality issues.

One by one, McCarty has addressed several concerns within the unit:

• In the rest rooms, handicap toilets were installed that are more easily accessible.

• An alert system was implemented that lets patients call a clinician at night when the Institute's emergency room isn't highly staffed.

• Adjustments were made to the pneumatic tube system so that samples could be sent more quickly to the laboratory.

While most ideas are generated from the monthly meetings held by McCarty, occasionally one is lifted from another department within Johns Hopkins. For instance, a system was recently implemented in which prior to arriving at the hospital, patients are sent packets of information on their upcoming surgery with reminders of what documentation they should bring.

This concept, says McCarty, was borrowed from the endoscopy unit. However, the Eye Institute took it a step further and assigned a staff person to each incoming patient. With the new procedure, the point person calls the patient before and after the appointment to give instructions and get feedback. “It gives patients a common face and a voice that they get to know. It's really proven to be successful,” says McCarty. “We've just done a lot of simple things that have improved patient flow, patient satisfaction, and in some cases, patient safety.”

Going forward

Six years after the program took off, Rosenstein believes it has exceeded expectations - and he has numbers to back it up. According to data gathered from clinician surveys, the staff's impression of management's commitment to patient safety “has gone up significantly in the past few years. We think one of the key reasons is that the executives and hospital leaders are out on the units,” he says.