Publication Reveals How Utilizing a Cooperative High Reliability Organization Dramatically Cuts Patient Safety Errors by Over 70%


March 1st, 2017

The High Reliability Organization Council and Sepsis Alliance are calling attention to the most recent issue of Patient Safety and Quality Healthcare. The publication conducted an extensive profile on the Cooperative High Reliability Organization, the latest in a long line of military innovations that could dramatically improve healthcare and patient safety.

The United States’ Military has often been on the forefront of finding unique, creative ways to improve safety. In 1935, a bomber crash where critical safety protocols were overlooked prompted airmen at Wright Air Base near Dayton, Ohio to create the very first safety checklist. It is estimated that checklists went on to reduce safety errors by hundreds of thousands of lives annually in aviation. This was a substantial improvement in safety when compared to the typical failure rates involving human error in other industries. For instance, the healthcare industry has a 1.1% error rate that leads to fatalities, while aviation maintains an astonishing .00016% error rate leading to fatalities.

While military aviators pioneered the concept of a safety checklist, it was healthcare and other industries that truly benefited from the concept. In the healthcare setting, safety checklists have been shown in major studies to reduce serious preventable infections — in fact, by 66% in one 18-month study across multiple hospitals in Michigan that started in 2003.

Eighty years later, in 2015, Wright-Patterson Air Force Base pioneered the launch of the CHRO as another means to improve safety and reliability in a variety of settings and, in recent studies, has reduced a variety of preventable problems by over 70% in multiple hospitals, especially in the prevention of high cost and high mortality complications.

The CHRO, implemented in the study through a grant from the High Reliability Organization Council (HROC), consists of a change in thinking in hospitals with the development of a new “battle formation” for teams, as well as a new set of tools (including manual, as well as automated electronic methods), all designed to help prevent task saturation. As profiled in Patient Safety and Quality Healthcare, the CHRO led to a dramatic decrease of nearly 73% in the deadly preventable complication of most infections, known as sepsis.

The success in reducing sepsis, an often-fatal condition that just over half of Americans have ever even heard of, attracted the attention of Sepsis Alliance. Sepsis Alliance is the nation’s leading patient advocacy organization, dedicated to raising the alarm on sepsis and its devastating impact. “Sepsis is one of the most significant health threats facing us today, and any breakthrough in that area is welcome news,” said Tom Heymann, Executive Director of Sepsis Alliance. “What the CHRO has achieved in this initial study shows incredible promise for the future, and a means where healthcare providers can improve patient safety using existing assets within the healthcare system. Solving this $24 billion per year problem could go a long way towards reducing healthcare costs and, more importantly, saving lives.”

Patient safety researcher for HROC and lead author, Lt. Col. Jared Mort, added, “We implemented the CHRO as a new care delivery model to improve safety while reducing costs for patients with sepsis and infections. The key findings were that antibiotic time-to-treatment dropped by 62.4%, and preventable sepsis-related complications dropped by 72.7%. The costs of infections that increased from delays, as well as the costs of hiring more team members to look at all the checklist tasks to prevent those infections, were reduced, as well.”

When it comes to healthcare, technology does not yet offer the failure-preventing “fault tolerance” levels that are so prevalent in aviation. As a result, providers must rely more on physicians, nurses, and other individuals in the healthcare system to find and prevent errors.

Ironically, part of the reason that safety could be improved in CHRO studies so dramatically, even while spending fewer man-hours and using less medications, is because the checklist invention itself became too successful. “Checklists have become so overused in the hospitals studied that many experience ‘checklist overload’,” added Lt. Col. Mort. “This condition has been noted by practitioners as pervasive both in Military and VA healthcare, and has become a major threat to people trying to maintain high standards of reliability.”

The reason for this is a phenomenon seldom acknowledged or tackled within most organizations called task saturation. Task saturation refers to the innate capacity of the human mind to handle only a finite amount of information at any given moment.

Studied extensively by the U.S. Air Force as a means of reducing fighter jet crashes, task saturation overwhelms the individual saddled with too much to do in too little time, leading to mistakes and delays. It is a common occurrence in many industries, and an acute issue in healthcare where those mistakes and delays can often mean the difference between life and death.

The new peer-reviewed study profiled in Patient Safety and Quality Healthcare showed checklist overload tasks decreasing by 73.7%, including a dramatic reduction in the number of safety-related electronic alerts for the cohorts targeted.

A previous study of the CHRO results at Wright-Patterson, geared specifically toward the reduction of checklist overload, showed an incredible drop in preventable deaths by 87% when the CHRO’s “protected flanks” concept was implemented broadly by nursing teams. The latest study proved that even in a setting with a sophisticated Electronic Health Record found in the civilian hospital, the results can be dramatic, as shown by the nearly 73% reduction in preventable complications.

The CHRO is a joint collaboration between the U.S. Air Force, the non-profit High Reliability Organization Council, and Johns Hopkins, and was originally studied as part of a defense project through a branch of the U.S. Army known as the Telemedicine and Advanced Technology Research Center. The study came at the urging and initiative of Congressional interest in the emerging science behind the project.

To learn more about CHROs and their potential impact in healthcare, visit:

http://www.thinkhro.org

And for more information on sepsis awareness, detection, and treatment, please visit:

http://www.sepsis.org
About HROC

HROC (http://www.thinkhro.org) is a registered non-profit committed to scientific study and public safety, and serves as a platform for education and collaboration, supporting and assisting in the implementation of High Reliability Organizations (HRO) in healthcare, government, and nonprofit entities. It arose from over 2 years of pro bono work by ProcessProxy Corp. with the U.S. Air Force in a Cooperative Research And Development Agreement. HROC members are clinicians, researchers, veterans, and HRO practitioners on the frontline of educating the public on the need for healthcare to adopt HRO principles in the interest of significantly improving both patient and public safety.

About Sepsis Alliance

Sepsis Alliance is the nation’s leading sepsis advocacy organization, dedicated to saving lives by raising awareness of sepsis as a medical emergency. A 501(c)(3) organization, Sepsis Alliance was founded by Dr. Carl Flatley after the sudden, unnecessary death of his daughter Erin to a disease he had never even heard of. Sepsis Alliance produces and distributes educational materials for patients, families and health providers on sepsis prevention, early recognition and treatment. The organization also offers support to patients, sepsis survivors, and family members through its sepsis.org website which receives more than 1 million visits each year. The organization founded Sepsis Awareness Month in 2011, and works with partners to host community outreach events across North America. Since Sepsis Alliance began its mission, sepsis awareness has increased almost threefold, from 19% to 55%. For more information on Sepsis Alliance, a GuideStar Gold-rated charity, please visit http://www.sepsis.org.

Sources

http://www.psqh.com/magazine/the-cooperative-high-reliability-organization-approaching-a-zero-defect-culture/

2012 Dept. of Transportation statistics; Leapfrog Group Hospital Safety Score, 2013

CDC Hospital Inpatient Statistics, 2013

Leapfrog Group Hospital Safety Score, 2013

2012 U.S. Dept. of Transportation

http://www.nature.com/news/hospital-checklists-are-meant-to-save-lives-so-why-do-they-often-fail-1.18057