Center for Patient Safety
Research and Practice
David Bates, MD, MSc
Center Director
Overview
Background
 Accomplishments to date
 Before the Center
 Of the Center itself
 Other related
 Future vision
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Safety and Systems
“Safety is a systems property.”
Chasm Report
“Every system is perfectly
designed to achieve exactly the
results it gets.”
Donald Berwick
National Developments
CMS announced plan 4/14 to stop paying
for Serious Reportable Adverse Events
(“never” events)—n=28
 FDA has announced plans to develop
“Sentinel Network”
 Agency for Healthcare Research and
Quality devoting few resources to safety
research (main recent focus HIT)
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BWH As A Leader:
Inpatient Prevention—Computerized
Physician Order Entry
 55%
reduction in serious medication
error rate with CPOE
Bates, JAMA, 1998
 83%
reduction in overall medication
error rate
Bates, JAMIA, 2000
NEPHROS study
Effect of real-time decision support for
patients with renal insufficiency
 Of 17,828 patients, 42% had some degree
of renal insufficiency
Interv Control
Dose
67%
54%
Frequency 59%
35%
 Length of stay 0.5 days shorter
Chertow et al, JAMA 2001
Medication Systems
Then and Now
THEN
NOW
BCMA
Slide Courtesy of Anne Bane, RN, MSN. Brigham and
Women’s Hospital
Medication
Location
Real Time Alerts to Nurse
Slide Courtesy of Anne Bane, RN, MSN, Brigham and Women’s
Hospital
Dispensing Errors and Potential ADEs:
Before and After Barcode Technology Implementation
1.00%
0.80%
0.61%
0.60%
Before Period (115164
doses observed)
After Period (253984
doses observed)
0.88%
31%
reduction*
63%
reduction*
0.40%
0.20%
0.00%
Dispensing Error Rate
* p<0.0001 (Chi-squared test)
Projections for errors
prevented per year at
study hospital:
0.19%
 >13,500 medication
0.07%
dispensing errors
 >6,000 potential
ADEs
Potential ADE Rate
Poon, Ann Intern Med, 2006
Formal Cost Benefit Analysis
Results
5-year cumulative costs = $2.3M
 $1.4M one-time investment (pre golive, first 2 years)
 $343K/yr recurring (post go-live, last
3 years)
 5-year cumulative benefits = $5.5M
 5-year cumulative net benefit = $3.3M
 Break-even within 1st year after go-live

Maviglia, Arch Int Med 2007
Improving the Response to
Critical Labs
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Baseline revealed that a third not treated for 5
hours
Mean time to treatment11% shorter
Mean time to resolution 29% shorter
Mortality was 7% in intervention group, 13%
control group (p=0.19)
95% physicians pleased to be paged
Kuperman, JAMIA 2000
Coverage-Related Events
Before data showed patients being crosscovered at 5-fold excess risk of adverse
event
 After computerized signout introduction, no
excess risk
 Included medications
 Simple from informatics perspective but
major benefit

Petersen, Jt Comm Jl
Take-Away Messages of
Smart Pump Controlled Trial
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Serious IV med errors were frequent and could
be detected using smart pumps
However, no impact on the serious med error or
preventable ADE rate was found
 Likely because of poor design and also
compliance
Behavioral and technologic factors must be
addressed if smart pumps are to achieve their
potential for improving medication safety
Rothschild et al, Crit Care Med 2005
Reporting
and
Surveillance
Tool
Ambulatory
Pediatric
Epidemiology
Study
Improving
Safety in
Nursing
Homes
Safe
Intravenous
Infusion
Systems
Inpatient
Psychiatric
Epidemiology
Study
Organizational
culture in
promoting
patient safety
Dissemination Efforts (I)
Newsletter
 Website: www.coesafety.bwh.harvard.edu
 Presentation of findings at national
meetings
 SGIM, AMIA, NPSF, NICHQ, SCCM,
Annual AHRQ Patient Safety Conference
 Harvard CME Course on Patient Safety
 ITV Patient Safety Special

Dissemination Efforts (II)
AHRQ Webcast
 Dr. Bates, Gurwitz served on recent IOM
Committee
 WHO
 Dr. Leape led drafting of WHO
Guidelines for Adverse Event Reporting
and Learning systems
 Dr. Bates leading development of global
agenda for patient safety research

HIT-CERT Studies
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Automated telephone surveillance in outpatients
prescribed specific medications to determine whether
or not they are experiencing specific ADEs
Evaluation of the impact of clinical decision support
and automated telephone outreach on antihypertensive
and lipid-lowering therapy
Characterization of new errors with ambulatory
electronic prescribing
Post-discharge ambulatory medication reconciliation
Evaluation of multiple vendor-based electronic
prescribing systems and health information exchange
on outpatient medication safety in Mass and New
York
Identification with AMIA of a set of clinical decision
support rules that can be used in multiple settings
Other Grants
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Study beginning supported by Pfizer to study
automation of ambulatory adverse drug event
reporting
Study of safety climate in nursing homes
underway
Closing the loop on missed and delayed diagnoses
Support to study role of pharmacists in the ED
Study of the impact on safety of a chemotherapy
robot
Study of impact of attending fatigue on error rates
Study funded by Aetna looking at personalizing
breast cancer care based on genomic data
Funding from WHO to assess global burden of
patient safety
Massachusetts eHealth Collaborative
Effort to get all providers in state to use
electronic records
 Have given EHRs and set up clinical data
exchange in 3 communities
 Evaluating impact on quality, safety, and
efficiency
 A potential model for rest of U.S.
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Areas of Particular Interest
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Medication safety
Surgical safety
Nosocomial infections
Improving monitoring
 Of patients
 Of devices
Diagnostic error
Using technology effectively
Safety culture/organizational interests
Vision for Center
BWH has long been leader in this area
 Multi-institutional, multi-disciplinary
program
 Goal to bring together the best in this area
 Provide core support, foster collaboration
 Already have many investigators working
in parallel
 Longitudinal focus is essential—problem is
not going to go away
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