Schueler, Nicole

Objectives: A framework of high-reliability principles was used to identify, investigate, and mitigate infusion pump safety concerns at a large, multisite health care system. We developed a systematic approach to address challenges associated with overinfusions, underinfusions, and the inability to clear upstream occlusion alarms. We identified 112,875 upstream occlusion events for 389,604 infusion starts (failure rate, 29%) within 6 months. Methods: Five high-reliability principles were applied to infusion pump management. Preoccupation with failure emphasized reporting safety concerns and performing appropriate clinical and bench tests. Deference to expertise prompted the development of a multidisciplinary team with internal and external partners. Sensitivity to operations prompted assessment of human factors design, with simulations and analysis of medication-specific factors (e.g., viscosity; infusion rates). Reluctance to simplify prompted assessment of tubing characteristics (e.g., concentricity; wall thickness) with micro–computed tomography and process development for removing faulty equipment. Practice of resilience ensured ongoing engagement and commitment to a culture of safety and patient advocacy. Results: The multidisciplinary oversight team prompted a national recall, removal of malfunctioning pumps, and development of system-wide training and mitigation protocols. Despite ongoing pump challenges, our team optimized internal patient safety systems and processes. The cause of these malfunctions remains under investigation, but serious patient harm has been prevented. Conclusions: Key strategies for enhancing patient safety were continuous vigilance, interdisciplinary collaboration, and embracing complexity in a large health care organization. Future directions involve deeply integrating these high-reliability principles across all aspects of health care delivery to continue improving safety and quality outcomes.

Objectives Patient safety incident reporting in our institution’s intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes organizational learning from near misses. We aimed to increase the ICU number of patient safety incident reports by 30% from 27 to 35 reports/1000 patient-days without negatively impacting culture of safety as measured by patient-care staff surveys. Methods Single-institution prospective interventional study with 9 ICUs receiving a multifaceted intervention developed using quality improvement methodology during February–April 2022. Study intervention involved creation of patient safety peer-leadership role, feedback process, interactive dashboards for patient safety data, and education resources accessible via quick response codes. Primary outcome was patient safety incident reports/1000 patient-days. Intensive care unit patient-care staff culture of safety was assessed with surveys. Results Intensive care unit patient safety incident reporting increased by 48% after intervention (40 versus 27 reports/1000 patient-days [P = 0.136]). Near misses were the most common incident report. Intensive care unit patient-care staff ratings of patient safety did not change; 80% rated patient safety as good or better after intervention versus 78% at baseline (P = 0.465). However, significant improvement was observed for subcomponents related to learning culture and support for staff involved in patient safety incidents. Most reports (>80%) were submitted by nurses. Conclusions This multifaceted quality improvement intervention increased patient safety incident reporting in the ICUs. Increases in ratings of learning culture and support for staff underline the importance of a well-functioning patient safety incident reporting system in an institutional culture of safety.