harvard school of public health making health care safe: easier said than done lucian l. leape, md...
TRANSCRIPT
![Page 1: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/1.jpg)
HARVARD SCHOOL OF PUBLIC HEALTH
Making Health Care Safe:Easier Said Than Done
Lucian L. Leape, MD
Dana-Farber Cancer Institute January 23, 2004
![Page 2: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/2.jpg)
Safety:
Freedom from accidental injury
![Page 3: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/3.jpg)
Medical Practice Study
Records reviewed
Positive screen
Adverse Events
Preventable AE
Deaths
30,000
7,817
1,133 (3.7%)
788 (2.5%)
157 (0.5%)
![Page 4: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/4.jpg)
The Extent of Medical Injury
New York MPS ‘91 3.7% CO/UT MPS ‘99 3.1% Australia ‘95 13% UK ‘00 10% Denmark ‘01 9% New Zealand ’01 11% Utah ICD-9 listing ‘01 8.5%
![Page 5: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/5.jpg)
Adverse Drug Event Studies
PrevStudy ADE ADE
Leape ‘91 (Records) 0.7% 0.4 %
Bates ‘95 (Solicit +) 6.5% 2 %
Gandhi ‘03 (Patient) 25 % 3 %
![Page 6: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/6.jpg)
The idea that medical errors are caused by bad systems is a transforming concept
![Page 7: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/7.jpg)
Lessons from Cognitive Psychology
1. Errors are normal behavior
2. The causes of errors are not obscure
![Page 8: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/8.jpg)
Causes of Errors
Habit Anger
Interruptions Anxiety
Hurry Boredom
Fatigue Fear
![Page 9: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/9.jpg)
Cognitive Dispositions to RespondCognitive Dispositions to Respond
Aggregate bias Gender bias Representativeness restraint
Anchoring Hindsight bias Search satisficing
Ascertainment bias Multiple alternatives bias Sutton’s slip
Base-rate neglect Omission bias Sunk costs
Commission bias Order effects Triage cueing
Confirmation bias Outcome bias Underconfidence
Diagnosis momentum Overconfidence Unpacking principle
Feedback sanction Playing the odds Vertical line failure
Framing effect Posterior probability error Visceral bias
Fundamental attribution error Premature closure Yin-Yang out
Gambler’s fallacy Psych-out error Zebra retreat
![Page 10: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/10.jpg)
Parisin the
the Spring
![Page 11: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/11.jpg)
b
![Page 12: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/12.jpg)
To err is human,
To forgive, divine
Alexander Pope
![Page 13: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/13.jpg)
Man - a creature made at the end of the week when God was tired.
Mark Twain
![Page 14: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/14.jpg)
Lessons from Cognitive Psychology
1. Errors are normal behavior
2. The causes of errors are not obscure
3. Human errors result from latent errors
![Page 15: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/15.jpg)
Latent Errors
Design of work Conditions of work Training Design and maintenance of equipment
![Page 16: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/16.jpg)
Latent Errors
Design characteristics that induce errors:
a) Create conditions that generate known causes of errors
OR
b) Require work that exceeds the capacity of the human brain
![Page 17: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/17.jpg)
The Real WordHealthy appearing decrepit 69 year old male,
mentally alert but forgetfulThe skin was moist and dryOccasional, constant, infrequent headachesPatient was alert and unresponsiveRectal examination revealed a normal sized thyroidShe stated that she had been constipated for most
of her life, until she got a divorce
![Page 18: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/18.jpg)
Accident Causation Model
ACCIDENT
Latent Errors
Systems Defects
Triggering Factors
UnsafeActs
Def
ense
s
Errors
Def
ense
s
![Page 19: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/19.jpg)
Human Factors Principles
Avoid reliance on memory Simplify Standardize Use constraints and forcing functions Use protocols & checklists wisely Avoid long hours and fatigue Match work loads to capacity
![Page 20: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/20.jpg)
Human Factors Violations
Reliance on memory
Excessive number of handoffs
Non-standard processes
Resist use of protocols
Long work hours
Excessive work loads
![Page 21: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/21.jpg)
![Page 22: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/22.jpg)
![Page 23: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/23.jpg)
![Page 24: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/24.jpg)
Examples of Systems Redesign
Warfarin clinics Heparin protocols Removal of KCl from nursing units Reconciling medications on admission
and discharge Matching on-call schedule to load
![Page 25: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/25.jpg)
Types of Systems
Process, tasks, and equipment Education and training Teamwork and interpersonal relationships Conditions of work Organizational culture
![Page 26: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/26.jpg)
What Have We Learned? Systems Theory works in health care Hospitals can make substantial reductions in
errors by applying known safe practices Collaboration is a powerful mechanism for
advancing patient safety Leadership and champions are essential Reporting works when it is safe and
productive
![Page 27: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/27.jpg)
Progress in safety is too slow
Most hospitals have implemented only a few simple safe practices
Cultures haven’t changed There is great resistance to taking on the serious
issues: working conditions, full disclosure, teamwork No evidence that care is safer Public / media perceive little improvement
![Page 28: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/28.jpg)
Barriers to progress in patient safety
Complexity Pressure of concerns about costs Lack of leadership Physician resistance
![Page 29: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/29.jpg)
Barriers to progress in patient safety
Complexity- 9,000 drugs (v. 600 in 1960)- 77,000 lab tests per year- 5,000 prescriptions per year- Ever-changing technology- Multi-specialty, multi-professional teams- Expanding knowledge base
![Page 30: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/30.jpg)
Barriers to progress in patient safety
Complexity Pressure of concerns about costs
- Public is more concerned about access
- Doctors are more concerned about falling income and rising malpractice premiums
![Page 31: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/31.jpg)
Barriers to progress in patient safety Complexity Pressure of concerns about costs Lack of leadership
- CEOs don’t want to believe the numbers- Can’t get too far ahead of doctors- Not feeling much heat from public, boards or regulators
![Page 32: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/32.jpg)
Barriers to progress in patient safety
Complexity Pressure of concerns about costs Lack of leadership Physician resistance
![Page 33: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/33.jpg)
Physician Resistance
Don’t believe the numbers Don’t want to believe them Don’t square with personal experience
- Most mistakes are not recognized Autopsy studies:
Major unsuspected dx 20-40%Probable cause of death 10-20%
- “Tyranny of small numbers”
![Page 34: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/34.jpg)
The Tyranny of Small Numbers
No. of practicing physicians ~ 600,000
No. of preventable deaths/yr ~ 100,000
![Page 35: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/35.jpg)
The Power of Numbers
Prescriptions = 3,000,000,000
X 10% error rate = 300,000,000
X 10% are serious = 30,000,000
X 20% cause ADE = 6,000,000
X ? 1% are fatal = 60,000
![Page 36: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/36.jpg)
Physician Resistance
The transforming concept is hard to accept
Vague and complicated Goes against everything we were taught Smacks of irresponsibility Offends our sense of free agency Offends our sense of equilibrium
![Page 37: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/37.jpg)
Physician Resistance
Don’t believe the numbers The transforming concept is hard to accept Fear
- Shame and guilt
- Loss of reputation
- Punishment
![Page 38: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/38.jpg)
Creating a Culture of Safety
1. How do you prevent accidental injuries?
2. What do you do when they occur?
![Page 39: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/39.jpg)
Creating a Culture of Safety
How do you prevent injuries? Implement safe practices
- Which ones?- How are they enforced?
Implement new policies- Is it safe to talk about mistakes?- Are the conditions safe?- Is there mutual respect?- Is everyone accountable?
![Page 40: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/40.jpg)
Creating a Culture of Safety
1. How do you prevent accidental injuries?
2. What do you do when they occur?
![Page 41: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/41.jpg)
Creating a Culture of Safety
How do you respond to injuries?
What happens when someone reports a serious event?
What happens to the patient? What happens to the caregiver?
![Page 42: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/42.jpg)
Patient’s Concerns
Pain and dysfunction caused by injury Worry about prognosis Injury caused by trusted caregiver Continue to be cared for by those who hurt
them
![Page 43: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/43.jpg)
Patients’ Needs After Injury
1. Know what happened
2. Receive an apology
3. Be assured the hospital is doing all it
can to prevent a recurrence
![Page 44: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/44.jpg)
Full Disclosure
Clear, well-understood policy Strongly supported by the CEO, the
Board, and Department Chairmen How it is done is as important as doing
it.
![Page 45: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/45.jpg)
The “Second Victim”
Often overlooked Shame, guilt and fear can be profound Impaired ability to deal with patients Needs colleagues’ support May need psychological counseling
![Page 46: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/46.jpg)
Safety is not a program, it is a
way of life
![Page 47: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/47.jpg)
Success Stories
Roger Resar Eau Claire, WI
Paul Uhlig Concord, NH
![Page 48: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/48.jpg)
Luther-Midelfort Safety
Non-punitive Error Reporting Leadership Training Videos and Education Culture Surveys Principles of Medication Administration Discharge Medication Calendars
![Page 49: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/49.jpg)
Luther-Midelfort Protocols
Sliding Scale Insulin Hypoglycemia Coumadin Heparin Admission
Reconciliation Discharge
Reconciliation
Renal Dosing Potassium
Replacement Neuromuscular
Blockade (Ventil) Resuming Home
Medications Pain Management Sedation (Ventil)
![Page 50: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/50.jpg)
ADE’s/1000 DosesADE’s/1000 DosesLuther Midelfort Mayo Health SystemLuther Midelfort Mayo Health System
![Page 51: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/51.jpg)
% of INR out of Therapeutic Range Luther Midelfort Mayo Health SystemLuther Midelfort Mayo Health System
![Page 52: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/52.jpg)
The Concord Cardiac Team
Nurse-Practitioner Cardiac Surgeon Card Surg Resident Physician Assistant ICU nurses Pharmacist Physical Therapist Occupational Therapist
Dietician Social worker Spiritual care giver Outpt Coordinator Office nurse Patient Family members
![Page 53: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/53.jpg)
Concord Cardiac Results
Patient satisfaction: up Employee morale: up Surgical complications: down Surgical mortality: down
![Page 54: HARVARD SCHOOL OF PUBLIC HEALTH Making Health Care Safe: Easier Said Than Done Lucian L. Leape, MD Dana-Farber Cancer Institute January 23, 2004](https://reader035.vdocument.in/reader035/viewer/2022062407/56649cf75503460f949c72a5/html5/thumbnails/54.jpg)
Operative MortalityConcord Cardiac Surgery
7/6/98 to 10/4/01
0
10
20
30
40
0 100 200 300 400 500 600
sequential patients
death
s
expected
observed
Institution of collaborative rounds