The science of safety: Duke moves in a new direction to improve patient safety

Changes occur after organ transplant sentinel event

In the aftermath of a tragic sentinel event traced back to poor processes, the appointment of Karen Frush, MD, as the new patient safety officer at Duke University Hospital System (DUHS) in Durham, NC, raises several immediate questions.

What does she plan to do differently?

And how can her work help prevent another error of that magnitude?

Frush, already chief medical director for children’s services at Duke, will continue in that role as she takes on the patient safety position that Duke spent a year filling. Duke launched the search after a 2003 incident at Duke University Hospital in which a heart and lungs with the wrong blood type were mistakenly transplanted into a 17-year-old girl. The girl subsequently died, and Duke admitted that its processes for preventing such a grievous error were inadequate.

"I think that event helped clarify the need to work together and have a more formal structure," Frush says. "Although a lot of people at Duke were doing a lot of things in patient safety, you ended up reinventing the wheel and not learning from each other. There’s too much to do to all be doing it individually."

The transplant error helped Duke understand the complexity of the health system and the high risk of much of what happens in health care, she says. "It clarified a need to allow someone the time to focus on patient safety at a physician level, at an administrative level. We knew that patient safety was important, but that incident underscored that we needed to move in a more focused, determined effort," Frush says.

She will spend 75% of her time on patient safety and 25% as a clinician in the pediatric emergency department, which she says will keep her grounded in the day-to-day clinical realities of patient safety.

As the first chief patient safety officer for DUHS, Frush will be responsible for developing a comprehensive patient safety program across all components of the health system and will provide leadership in strategic planning, analysis, development, implementation, and measurement of patient care quality and safety initiatives. The chief patient safety officer will work closely with leaders at Duke University Hospital, Durham Regional Hospital, Duke Health Raleigh Hospital, the Private Diagnostic Clinic, Duke University Affiliated Physicians and Duke Health Community Care. Frush begins her new responsibilities immediately and will report directly to Victor Dzau, MD, chancellor for health affairs at Duke University and president and CEO of DUHS.

She will work closely with the CEOs, chief nursing officers, patient safety officers, and risk managers at each individual Duke facility. Duke has a system-level risk manager and also one at each facility; Frush says she intends to work closely with them to carry out patient safety goals. Most of her contact with risk managers will be through a health system-level committee for patient safety that she will chair. The system risk manager also is on the committee and the hospital’s individual risk managers will be involved in specific projects.

"I see this as a great opportunity to work closely with health system and hospital leadership, as well as physicians and staff on the front lines of patient care. After all, this is where the outcomes of patient safety efforts are ultimately determined," Frush says. "The hospital leadership and all the staff at the hospital need to own patient safety, so it’s not my place to dictate exactly what their structure looks like. I provide enough guidance so they understand that it’s multidisciplinary and they need the input of many different areas."

Role is to provide the big picture

Frush’s job is to provide the big picture for patient safety, she says, and then the risk managers and other leaders will implement that vision in the ways most appropriate to their own facilities. She plans to spend most of her time as patient safety officer at the hospitals, talking to not only leadership but also the frontline staff. "Patient safety happens at the bedside, not in the boardroom," she says.

Frush says her background in pediatric emergency medicine guided her interest in patient safety because so much of that work involves protecting children from accidents and treating them after trauma. "I believe strongly that we are human and accidents happen, but that’s why we have to do all we can to look at the system within which we work to build safety nets and mechanisms into the system so that when we make mistakes that won’t lead to an adverse outcome for the patient," she says.

Frush’s plans as chief patient safety officer include the development of a Patient Safety Center at Duke to further the clinical understanding of the science of safety. The center will support educational initiatives, clinical research and outreach opportunities related to safety.

"This is not just an administrative position. The patient safety officer needs to promote learning and research into patient safety, because everyone, including myself, needs to learn a lot more," she says. "At an academic medical center such as this, we have incredible resources around us, people who are really smart in our medical school, nursing school, and training as residents. We need to use those resources to learn whether our structure for patient safety really works, what mechanisms we can put in place."

The Patient Safety Center will provide support for that work with a statistician, a research assistant, and other aid. Residents and fellows with great ideas can turn to the center for the assistance they need to carry out the research and implement changes, Frush says.

She also plans to make more use of simulation labs to help teach clinicians about teamwork and the concept of "crew resource management," which encourages all team members to take responsibility for protecting the patient and to speak up when they see potential problems. "We have some learning to do and some retraining to do in terms of how we respect each other’s input," Frush says. "We can still have a team leader, but it’s a team leader who takes into account the views of the rest of the team, because the patient’s safety is most important."

Analytical yet humanistic

Frush intends to emphasize an "analytical-yet-humanistic" response to adverse events at Duke. That means the health system will encourage a blame-free environment but still hold people responsible for their willful disregard of patient safety, she explains. "If one of our providers chooses to intentionally go against policy, whatever we have in place to protect patient safety, that’s an accountability issue," she says. "You still have to go through a process to analyze the problem and identify the systems issues, but there’s human error and there’s system error. Ignoring safety policies that were put in place to protect patients needs to be addressed."

Frush says it can be tough to balance a blame-free environment with holding individuals accountable when they intentionally, knowingly violate a rule, but that it must be done to protect patient safety.

Duke also has formed safety teams on each unit that conduct rounds to talk with all the staff and families. The teams are made up of nurses, physicians, and others who focus on the particular risks inherent in that unit.

Frush says she sees the patient safety improvements at Duke as a potential source of improvement for other health care providers. "Part of our goal is to have a center for educational research and training that is helpful not just to folks at Duke but well beyond," she says. "We certainly want to, and will, share the lesson we learn with others. We learned some tough lessons with the organ transplant event, and as we learn other lessons we want to share them so that others don’t go through the same thing."