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ORIGINAL ARTICLE
Implementing and Validating a Comprehensive
Unit-Based Safety Program
Peter Pronovost, MD, PhD,*† Brad Weast, MHA,‡ Beryl Rosenstein, MD,§ J. Bryan Sexton, PhD,*
Christine G. Holzmueller, BLA,* Lori Paine, MSN,† Richard Davis, PhD,†
and Haya R. Rubin, MD, PhD*
Background: The IOM identified patient safety as a significant
problem. This paper describes the implementation and validation of
a comprehensive unit-based safety program (CUSP) in intensive care
settings.
Methods: An 8-step safety program was implemented in the
Weinberg ICU, with a second control (SICU) subsequently receiving
the intervention. Unit improvement teams (physician, nurse, administrator) were identified to champion efforts between staff and Safety
Committee. CUSP steps: (1) culture of safety assessment; (2) sciences of safety education; (3) staff identification of safety concerns;
(4) senior executives adopt a unit; (5) improvements implemented
from safety concerns; (6) efforts documented/analyzed; (7) results
shared; and (8) culture reassessment.
Results: Safety culture improved post versus pre-intervention (35%
to 52% in WICU and 35% to 67% in SICU). Senior executive
adoption led to patient transport teams and pharmacy presence in
ICUs. Interventions from safety assessment included: medication
reconciliation, short-term goals sheet and relabeling epidural catheters. One-year post-CUSP implementation, length of stay (LOS)
decreased from 2 to 1 day in WICU and 3 to 2 days in SICU (P ,
0.05 WICU and SICU). Medication errors in transfer orders were
nearly eliminated, and nursing turnover decreased from 9% to 2% in
WICU and 8% to 2% in SICU (neither statistically significant).
Conclusions: CUSP successfully implemented in 2 ICUs. CUSP
can improve patient safety and reduce medication errors, LOS, and
potentially nursing turnover.
Key Words: safety, ICU, culture, CUSP, error, patient safety
(J Patient Saf 2005;1:33–40)
T
he Institute of Medicine (IOM) report ‘‘To Err Is Human’’
identified patient safety as a significant nationwide
problem and stated that efforts to improve safety must focus
on systems, not providers.1,2 These systems include technology,
From *The Johns Hopkins University, Baltimore, Maryland; †Johns Hopkins
Medicine, Center for Innovations in Quality Patient Care, Baltimore,
Maryland 21205; ‡319th Medical Group, Grand Forks AFB, North
Dakota; and §The Johns Hopkins Hospital, Baltimore, Maryland.
Correspondence: Peter J. Pronovost, MD, PhD, 901 S. Bond Street, Suite 318,
Baltimore, MD 21231 (e-mail: [email protected]).
Copyright Ó 2005 by Lippincott Williams & Wilkins
J Patient Saf Volume 1, Number 1, March 2005
practices, procedures, policies, and more broadly the culture in
organizations. Organizational culture is defined here as the
collection of values, beliefs, and assumptions that guide members’ behaviors,3 and is generally referred to as ‘‘the way we do
things around here.’’
In a safe culture, employees are guided by an organizationwide commitment to safety, in which each member upholds
their own safety norms and those of their coworkers.4 Evidence from aviation supports an association between a culture
of safety and better error management.5
The IOM report ‘‘To Err Is Human’’ spurred healthcare
organizations to implement initiatives that improve patient
safety.6 Understanding that culture changes incrementally and
that all staff must live a culture of safety, we sequentially
implemented a safety program. The comprehensive unit-based
safety program (CUSP) targets the work unit level, to engage
and empower staff to identify and eliminate patient safety
hazards. The specific aims of this investigation were: (1) to
implement and validate CUSP and demonstrate its validity
through a variety of measures in the ICUs at The Johns
Hopkins Hospital (JHH), and (2) to evaluate whether we could
disseminate the CUSP to a second ICU.
METHODS
Study Design and Population
We used a quasi-experimental design in which we implemented a safety program in the Weinburg ICU (WICU),
while another surgical ICU (SICU) served as the control. Six
months later, we implemented the intervention in the SICU.
Thus, we had two 6-month measurement periods (pre and
post) in the WICU, and three 6-month periods in the SICU
(pre, control, and post). These units were selected because
ICUs are high risk areas where mistakes are common and
because one of the authors (PP) is an attending intensivist in
both ICUs.7,8 The WICU is a 14-bed oncology surgical ICU,
and the SICU is a 15-bed surgical ICU that cares for general
vascular surgery, trauma, and transplant patients. In both ICUs,
all patients are co-managed by intensive care physicians and
surgeons, and the nurse to patient ratio is either 1:1 or 1:2.
Critical care fellows and surgery and anesthesiology residents
are assigned to the ICUs and care for all patients.
Development of the CUSP
As a work in progress, CUSP evolved through literature
review, discussion with experts, trial, and adaptation. Design
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of the program was influenced by participation in the Institute
for Healthcare Improvement’s Quantum Leaps in Patient
Safety. The goal of this program was to create a safety program
that: (1) could be implemented sequentially in work units,
(2) would improve the culture of safety, (3) would allow
staff to focus safety efforts on unit-specific problems, (4)
would help staff implement system wide safety initiatives, and
(5) would include rigorous data collection (ie, be able to be
published).
The foundation for this program was the unit improvement team. Each team included a physician, nurse, and a
senior executive, with pharmacists, respiratory therapists, and
other staff encouraged to participate. After discussions with
department chairs and nurse managers, it was decided that
improvement team members would dedicate 4 to 8 hours per
week to implement this improvement program.
CUSP is an 8-step program designed to impact safety
climate by empowering staff to assume responsibility for
safety in their environment. This is achieved through education, awareness, access to organization resources, and a toolkit
of interventions. CUSP is summarized below and outlined in
Table 1.
Step 2: Educate Staff on Sciences
Related to Safety
Once the cultural survey is complete, the unit is ready
to learn the science related to safety. The CUSP champion
(the physician co-chair of the patient safety committee (PCS)
or the nurse safety coordinator) presents this concept to
all unit staff, including physicians, nurses, pharmacists,
respiratory therapists, aides, and clerks in a 40-minute
presentation. This talk highlights lessons learned from ‘‘To
Err Is Human’’ and explores the potential impact of systems on the risk of an adverse event.2 The objectives of this
session are to help staff understand the following: patient
safety is a significant problem; efforts to improve safety
should focus on improving systems rather than blaming
caregivers; when harm occurs, it is preceded by a cascade of
system breakdowns; interpersonal skills, such as speaking up
when you have a concern, listening when others do, and
acknowledging personal and organizational vulnerabilities,
play a critical role in patient safety; and, finally, blame free
does not mean responsibility free—we all need to accept
responsibility for the systems in which we work. The CUSP
champion serves as a role model and remains the main point
of contact for the CUSP.
Step 1: Conduct Cultural Survey
The first step involves assessing the culture of safety on
the work unit. We used a medical derivative of aviation’s Safety
Climate Scale (SCS).5,9 This 10-item survey is answered using
a 5-point Likert scale (1 = strongly disagree to 5 = strongly
agree) (Appendix 1) and assesses the extent to which staff
perceive a strong and proactive organizational commitment to
patient safety.
The SCS, adapted from the flight management attitudes questionnaire, measures attitudes toward stress, status
hierarchies, leadership, and interpersonal skills.10 Scales and
individual items from the SCS questionnaires have demonstrated good reliability,11 internal consistency, and replicable factor structure.9,11 Moreover, it is predictive of pilot
performance5,12 and high speed rail incident rates,13 is sensitive to training interventions,14–17 and is used in medicine
to better understand the environments in which care is
delivered.18–20
Step 3: Identify Staff’s Safety Concerns
TABLE 1. Steps in the Comprehensive Unit-Based
Safety Program (CUSP)
Step 4: Executive Adopts a Work Unit
Step
1. Measure safety climate
2. Educate staff on the
science of safety
3. Identify staff’s safety concerns
4. Senior executive adopt a unit
5. Implement improvements
6. Document results
7. Share stories
8. Re-measure safety culture
34
Description
Survey staff
Talk presented to staff
-Ask staff what is broken
-Incident reporting
Senior executive meets
monthly with team
Select 3 interventions that do and
do not require marginal resources
Each project needs a metric
Web based safety tales
Survey staff
After the science of safety presentation, work unit staff
completes an open-ended safety assessment (Appendix 2) that
asks 3 questions: (1) Tell us about the last patient who would
have been harmed without your intervention. (2) How will the
next patient be harmed? (3) How can we prevent this from
happening–by either preventing the mistake, making the
mistake visible, or mitigating the harm should it occur?
This information is collected and summarized by the
PSC before the first unit meeting with the senior executive.
Issues presenting significant patient safety risks are discussed
immediately with the chairmen of the PSC. Summarized safety
concerns and an action plan are sent in letter form to work unit
participants and the senior executive (step 4) from the PSC. In
addition, we used an incident reporting system to help identify
patient safety hazards (http://icusrs.org, click ‘‘Members
Zone,’’ then ‘‘Training Form’’).
Next, members of the PSC meet with the senior
executive who will ‘‘adopt’’ the unit, present the science of
safety, and discuss the senior executive’s role in the CUSP.
From that point forward, the senior executive meets with unit
staff once a month to discuss results from the staff safety
assessment (step 3) and other staff concerns. These meetings
are intended to remove barriers to system changes, provide
resources for safety improvements, demonstrate the executive’s commitment to patient safety, provide coaching for
teams, and foster a trusting relationship between senior leadership and staff. The details of this step have been previously
published.21 The ability to provide rapid, useful, and accessible
feedback is an important means for developing trust and
creating a reporting culture.22
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Implementing and Validating a Comprehensive Unit-Based Safety Program
Step 5: Implement Improvements
Step 8: Repeat Cultural Survey
The next step is to implement improvements. First, work
unit staff selects areas in which to focus improvement efforts.
Areas are selected based on the institutional safety priorities,
results of the safety assessment, discussions, and historical
events. Staff are then instructed to prioritize improvement
efforts based on the probability of the event occurring and the
severity of harm should the event occur. We initially used a
prioritization matrix adapted from the VA to help select improvement areas.6 However, staff rarely used this form and it
was discontinued. Instead, staff relied on their knowledge of
the work environment to prioritize improvement efforts.
Once a priority list is compiled, staff is directed to select
2–3 improvement efforts that require minimal resources (ie,
funded out of their budget) and implement these immediately.
They also select 2–3 improvement efforts that require substantial resources (ie, require funding from the hospital) and
submit these to the PSC for review for possible funding. Staff
is encouraged to discuss needed resources with their senior
executive.
When selecting safety interventions, staff is asked to
consider 2 simple goals: (1) reduce complexity or the number
of steps in a process; and (2) create independent redundancies
or checks for key steps in a process, such as the use of
evidence-based therapies. An example of an independent redundancy is to have several individuals, such as a physician,
nurse, pharmacist, and patient or family member, check independent of one another to ensure that a patient’s medications
are appropriate or that barrier precautions are used when
inserting central lines.
Repeating the safety climate survey helps us evaluate the
success of the CUSP through the eyes of frontline personnel.
This is administered within 6 months of the baseline survey to
compare changes.
We administered the Safety Climate Survey (SCS) to all
WICU staff in June 2001 (pre-CUSP) and again in December
2001 (post-CUSP). Because the physician staff overlaps
between the WICU and SICU, we only surveyed nurses in
the SICU. SICU nurses completed 3 surveys (pre intervention
in June 2001, control period December 2001, and post
intervention June 2002). The potential response categories
were a 5-point Likert scale from 1 = strongly disagree to 5 =
strongly agree. We scored responses as the percent agreement,
that is, the percent of respondents who answered 4 or 5 to each
question. We summarized the percent of respondents who
scored 4 or 5 to all 10 questions as those reporting a positive
safety climate. To evaluate improvements in safety climate, we
only included respondents who completed both the pre and
post intervention surveys.
Step 6: Document Results
While each improvement effort has its own outcome
measure, the primary outcome measure of the CUSP was the
safety attitudes survey. Also, because improved culture may
lead to reduced complications and, thus, reduced length of stay
(LOS), and improved nursing satisfaction and, thus, reduced
nursing turnover, we evaluated the median ICU LOS and
nursing turnover rate as secondary outcomes.
Documenting results provides validity and the potential
for public dissemination. As such, teams are encouraged to
maintain methodological rigor in their data collection and
improvement efforts and to present data in annotated run
charts. Many improvement efforts falter because they fail to
collect measures and thus are unable to document their
impact.23 These types of efforts are often perceived by caregivers as unscientific efforts by hospital administrators to
reduce hospital costs. To overcome these barriers, we focus on
improving safety rather than reducing costs and create the
expectation that improvement efforts should be rigorous
enough for publication.
Step 7: Share Stories
Although a key element in organizational learning is to
share stories, we generally do this poorly. To help foster organizational learning, we created a standard report called
a Safety Tales Form. Staff uses this form to summarize and
disseminate improvement efforts.
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Interventions Implemented from CUSP
Several interventions were implemented during step 5
(Implement Improvements) of CUSP in the WICU and SICU.
One intervention was a short-term goals sheet (previously
published24). This form was used during daily rounds to
help ensure transparency among the care team regarding the
work needed to discharge the patient and to identify and
mitigate safety concerns. The goal sheet encourages staff to
explicitly state their care plan, tasks to be done, communication plan (with the team and family members), and safety
risks.
We also developed and implemented in both units a tool
to reduce medication errors in transfer orders by providing an
independent check for errors. This check involved the nurse
reviewing discharge orders and medical record at the time
of patient discharge from the ICU and answering 3 questions:
(1) Do the medications listed in the discharge orders match
what the patient is currently receiving? (2) Are allergies
listed correctly in the discharge orders? (3) Did the patient
start their home medications? If the answer to any question
was no, the nurse was instructed to ask the patient’s physician—generally the chief resident on the surgical service—if
they intended to make this change. The nurse then asked the
patient if the allergies and home medications were listed
correctly. Our definition of a ‘‘medication error’’ was if, as
a result of this process, the physician changed the discharge
orders. Our experience with medication reconciliation has
been published.25,26
Measurement and Analyses
All interventions were implemented during the intervention period. We defined nursing turnover as the
annualized percent of nurse full-time equivalents (FTEs)
who left their nursing unit, in this case the ICU. We measured
the mean nursing turnover in the WICU for the 6-month preintervention period (January 1 through June 30, 2001) compared with the same 6 months after the intervention (January 1
through June 30, 2002) to account for seasonal changes in
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turnover rates. We measured the mean turnover in the SICU for
the baseline period (July 1 through December 31, 2001),
control period (January 1 through June 30, 2002), and postintervention period (July 1 through December 31, 2002).
We measured the ICU LOS in the WICU for the 6month pre-intervention period (January 1 through June 30,
2001) compared with the same 6 months after the intervention
(July 1 through December 31, 2001). We measured the mean
ICU LOS in the SICU for the baseline period (July 1 through
December 31, 2001), control period (January 1 through June
30, 2002), and post-intervention period (July 1 through
December 31, 2002).
We used a x2 test to evaluate differences in responses to
the cultural survey and nursing turnover in the pre and post
periods. To evaluate differences in LOS, we used a t test. A P
value of less than 0.05 was considered significant. All analyses
were done with STATA 8.0.
RESULTS
Two surgical ICUs (WICU and SICU) have completed
all 8 steps of the CUSP. Described below are the results from
the WICU and SICU.
Cultural Survey
In the WICU, we received completed surveys from
66 people (89% response rate) in the pre-intervention period
and 64 people (86% response rate) in the post-intervention
period. In the SICU, we received completed surveys from 23
nurses (89% response rate) in the baseline period, 23 (89%
response rate) in the control period, and 21 (84% response
rate) in the post intervention period. Table 2 describes the
response rates by job category in the WICU and for nurses
only in the SICU.
Results of the cultural survey before and after CUSP
implementation in the WICU and SICU are presented in
Table 3. The percent of respondents who agreed (scores of 4 or
5 on the survey) increased for all 10 questions in the
TABLE 2. Respondents to Safety Attitudes Survey in
Pre- and Post-Intervention Periods
Pre
Intervention Period
Role
Number
Surveyed
Physician
Nurse in WICU
Nursing technician
Unit clerk
Support associate
Respiratory therapist
Pharmacist
Overall
Nurse in SICU*
10
40
3
4
8
2
7
74
26
Number
Responding
(%)
8
37
2
3
7
2
7
66
23
(80)
(93)
(67)
(75)
(88)
(100)
(100)
(89)
(89)
Post
Intervention Period
Number
Surveyed
12
38
3
4
8
2
7
74
25
Number
Responding
(%)
12
32
1
3
7
2
7
64
21
(100)
(84)
(33)
(75)
(88)
(100)
(100)
(86)
(84)
*Data only available for nurses, 89% response rate for control period (23 responders).
36
post-intervention survey relative to the pre-intervention
survey, with the SICU increasing more than the WICU.
In the WICU, the percent of respondents reporting
a positive safety climate increased to 52% from pre- to post
intervention, with 35% reporting a positive climate preintervention and 52% reporting a positive climate post intervention. In the SICU, the percent of respondents reporting
a positive safety climate almost doubled, from 35% pre to
68% post intervention, with results from the control period
remaining relatively similar to pre intervention (40%). These
results are summarized in Figure 1.
Interventions Implemented from CUSP
The staff’s safety concerns were similar in the WICU
and SICU. Examples of issues were lack of trained patient
transport teams, medication errors, and poor communication among ICU providers. Table 4 represents a summary of
concerns collected from the safety assessments and discussions with senior executives. The lessons learned from our
experience with senior executives adopting a unit have been
previously published.21
Senior executive engagement helped to improve patient
safety locally.27 Staff’s safety concerns prompted funding of
a patient transport team and a point of care pharmacist to
facilitate medication ordering and distribution.
Table 5 summarizes the staff’s plans to improve patient
safety with minimal and additional resources. A total of 5 safety
concerns identified were acted upon. Results from the safety
assessment indicated that staff perceived inadequate communication as a significant safety risk, particularly when patients
are transferred out of the ICU.
A short-term goals sheet was implemented to improve
communication among ICU team members and with family
members. The results of implementing the ‘‘daily goals’’ sheet
are published elsewhere.24
Medication reconciliation was associated with a significant reduction in medication errors.25,26 In the 2 weeks prior
to this intervention, 94% (31 of 33) of WICU orders contained
an error. After making the medication reconciliation a part of the
routine nursing discharge process, this type of error was eliminated.25 In the SICU, approximately 40% of charts contained
a medication error at transfer; these were also eliminated.26
Nursing Turnover
The CUSP was also associated with a reduction in
nursing turnover. There were 28 full-time nurses in the WICU
and 46 in the SICU during study periods. Nursing turnover
rates decreased from 9% (pre-intervention) to 2% (post
intervention) in the WICU and from 8% (pre-intervention) and
9% (control) to 2% (post intervention) in the SICU (Table 6).
Due to small sample size, these reductions were not statistically significant. The overall hospital nursing turnover rate
was 17% in 2001 and 15% in 2002.
LOS
The CUSP was associated with a reduction in LOS and
nursing turnover in both the WICU and SICU. In the preintervention period, the mean ICU LOS was 2 days in the
WICU and 3 days in the SICU. After CUSP implementation,
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Implementing and Validating a Comprehensive Unit-Based Safety Program
TABLE 3. Percent of Respondents Who Agree With Questions in Safety Attitude Survey
1. The senior leaders in my hospital listen
to me and care about my concerns.
2. The physician and nurse leaders in
my area listen to me and care about
my concerns.
3. My suggestions about safety would be
acted upon if I expressed them
to management.
4. Management/Leadership will never
compromise safety concerns
for productivity.
5. I am encouraged by my supervisors
and coworkers to report any unsafe
conditions I observe.
6. I know the proper channels
to report my safety concerns.
7. I am satisfied with availability
of clinical leadership (MD, RN, RPh).
8. Leadership is driving us to
be a safety-centered institution.
9. I am aware that patient safety
has become a major area for
improvement in my institution.
10. I believe that most adverse events occur
as a result of multiple system failures,
and are not attributable to one
individual’s actions.
Overall %
Agree
Pre-safety
Program is
WICU (N = 66)
Overall %
Agree
Post-safety
Program in
WICU (N = 64)
Relative %
Increase
Pre- Versus
Post-safety
Program
in WICU
Overall %
Agree
Pre-safety
Program in
SICU (N = 23)
Overall %
Agree
Post-safety
Program in
SICU (N = 21)
Relative %
Increase
Pre- Versus
Post-safety
Program
in SICU
43
58
35
52
67
29
50
71
42†
43
95
121†
40
61
53†
57
86
51†
52
67
29
65
67
3
56
76
36†
83
95
14
56
83
48†
74
90
22
47
76
64†
83
95
14
46
72
57†
52
81
56
63
89
41†
65
95
46†
62
87
40†
70
86
23
†P , 0.05 using x2 test for differences between period one and period two.
the WICU LOS decreased to 1 day (P , 0.05) (Table 6). In the
SICU, the LOS was 3 days in the pre-intervention and control
periods and 2.3 days in the post-intervention period (P , 0.05)
(Table 6).
FIGURE 1. The percent of staff in Weinberg ICU and surgical
ICU whose attitudes about safety (safety culture) were more
positive in the post-CUSP intervention survey compared with
pre-intervention.
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DISCUSSION
We described the implementation and validation of
a comprehensive unit-based safety program designed to
document measurable improvements in patient safety and
the concomitant improvement in local perceptions of patient
safety. The CUSP was associated with an improved safety
climate and reduced LOS, medication errors, and potentially
nursing turnover. Moreover, we were able to replicate these
results in a second ICU.
While much discussion has ensued regarding patient
safety, there are few examples where measurable improvements have been documented. In this study, we present a novel
safety program that can be implemented via a cascade-effect
throughout an organization and is associated with significant
improvements in patient safety. The CUSP’s unit-based
focus rather than organization-wide change is a more realistic
and manageable approach when initiating cultural change in
a large organization. The association between reduced nursing
turnover in both ICUs and improved culture of safety suggests
that the behaviors required to be a safe organization are similar
to the behaviors needed to improve employee morale, further
supporting the business case for safety. For both safety and
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TABLE 4. Staff Safety Concerns and Recommended Improvements Identified Through Safety Survey
Identified Concern
Recommended Improvements
Lack of standardized concentrations of vasopressors among ICUs and
operating room
Lack of trained team to transport patients from ICUs to remote testing sites
Risk of medication errors
Poor management of pain
Poor communication among ICU providers
Poor communication during ICU discharge leading to medication errors
in transfer orders
Epidural and intravenous catheters too similar in appearance
morale, staff needs to be part of a team in which they feel
empowered and engaged.
The CUSP evolved from our perception that many
efforts to improve safety were fragmented, lacked data regarding local culture, were unable to document improvements,
and did not engage work unit staff. We sought to develop
a program that integrated many aspects of patient safety, could
be implemented at the work unit level, had empirical results,
and would produce a cascade-effect throughout the JHH. One
advantage of CUSP is its empowerment of frontline staff to
assume responsibility for patient safety by generating issues,
prioritizing them, and implementing them according to local
needs. In addition, this program provides simple tools to
improve the culture of safety, a common metric to evaluate the
culture of safety, a standard approach to improvement, and
a system to disseminate results within the organization.
CUSP evolved through the lessons we learned during
these efforts. First, we learned to keep the tools simple. Second, we learned that ongoing discussions between senior
executives and work unit staff is imperative.27 Third, we
learned that staff needs time to work on improvement efforts if
the CUSP is to succeed. We ask each team member to devote
between 4 to 8 hours per week to our program. We do not
know why culture improvements in the SICU were greater
than those in the WICU. It may be the result of a learning curve
regarding how best to implement the program—the SICU
followed the WICU, or the early improvements in culture in the
WICU influenced the SICU.
We recognize several limitations to our program. First,
we have only implemented the program in ICUs and need to
evaluate the replicability of this program in other work units.
Need to standardize concentration and labels for vasopressor
Use dedicated transport team
Point of care pharmacist available on units
Create guideline or protocol for pain assessment and management
Create short-term goals sheet
Implement medication reconciliation process at ICU discharge
Make identification of catheters clear
Second, we implemented the program in an academic medical
center. It is unclear how this program would work in community hospitals. Third, we do not know the full impact of the
program yet. We do not have a wide sampling of the incidence
of adverse events and have not evaluated the long-term impact
of the program. Also, we cannot make causal statements about
the relationship between improvements in safety climate and
outcomes. Fourth, the instrument used to measure the culture
of safety could be improved and expanded. Sexton and
colleagues11 have developed a survey instrument that evaluates
job satisfaction, perceptions of management, teamwork climate, safety climate, stress recognition, and working conditions, thus providing keener insights into the organization’s
culture of safety.
Despite these limitations, we believe that the safety
improvements we have documented are significant and important to patients, families, and staff. To our knowledge, this
is the first study to document that climate of safety can be
improved in healthcare.28 The safety climate at JHH compares
favorably to aviation.5
CONCLUSIONS
We have validated CUSP in an ICU and replicated
improvements in patient safety in a second ICU at an academic
medical center, and demonstrated the validity through a variety
of outcomes. As a result, we improved staff’s perceptions
about patient safety and reduced ICU LOS, medication errors,
and potentially nurse turnover. These findings suggest that
healthcare organizations can improve patient safety and
provide evidence for the business case for safety. In closing,
TABLE 5. Action Items That Have Been or are Being Implemented
Identified Opportunity
Action Taken
Required
additional
resources
Dedicated patient transport team in order to improve
safety of transports
Point of care pharmacist: PharmD assigned to unit to
facilitate medication ordering and distribution.
Team initiated for ICU patients, but not for all shifts
Minimal
additional
resources
Goal sheets: Clarify short-term goals for patients in ICUs
Reconciliation: Reconciling pre-hospital, pre-operative, and
ICU medications before transfer from ICU
Labeling epidural catheters: Risk of medication errors if
epidural catheter is connected to intravenous catheters
Short-term goal sheet part of daily rounds
Medication reconciliation part of routine nursing discharge;
Audit of sample of charts is ongoing
Anesthesiologists in OR place orange sticker on epidural
catheters; ICU nurses also have these stickers
38
Funded and implemented in ICUs
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J Patient Saf Volume 1, Number 1, March 2005
Implementing and Validating a Comprehensive Unit-Based Safety Program
TABLE 6. Impact of CUSP on ICU LOS and Nursing Turnover
WICU
SICU
Pre Intervention
Post Intervention
Pre Intervention
Control
Post Intervention
674
2.2 (5.1)
9%
641
1.1 (4.1)†
2%
868
3.1 (5.0)
8%
749
3.0 (5.2)
9%
751
2.3 (3.6)†
2%
# of ICU admissions
ICU LOS (SD)
Nursing turnover
†P , 0.05 with t test comparing pre versus post groups. Changes in nursing turnover were not statistically significant.
we recently truncated CUSP into six steps with the development of a new tool to investigate safety defects. We believe
this shortened version will fit easily into staff’s daily routines.
ACKNOWLEDGMENTS
Partial funding for research activities provided by
the Agency for Healthcare Research and Quality (grant
#U18HS11902-01).
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J Patient Saf Volume 1, Number 1, March 2005
APPENDIX 1. Cultural Survey Questionnaire
We are conducting a survey to evaluate the culture of safety in your unit. The survey will take approximately three minutes to complete.
Please leave the completed survey in the survey mailbox or designated point of contact from your unit.
Role (circle one): Attending/Fellow Physician / Resident Physician / Nurse / Respiratory Therapist / Support Associate / Other (please list):______
Unit (please write in title and/or location):______ Date: ______
Please circle one answer per question
1. The senior leaders in my hospital listen to
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
me and care about my concerns.
2. The physician and nurse leaders in my area
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
listen to me and care about my concerns.
3. My suggestions about safety would be acted
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
upon if I expressed them to management.
4. Management/Leadership will never compromise
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
safety concerns for productivity.
5. I am encouraged by my supervisors and coworkers
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
to report any unsafe conditions I observe.
6. I know the proper channels to report my safety concerns.
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
7. I am satisfied with availability of clinical
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
leadership (MD, RN, RPh).
8. Leadership is driving us to be a safety-centered institution.
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
9. I am aware that patient safety has become a
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
major area for improvement in my institution.
10. I believe that most adverse events occur as a
Agree 5
Somewhat agree 4
Neutral 3
Somewhat disagree 2
Disagree 1
result of multiple system failures, and are not
attributable to one individual’s actions.
Thank you for engaging in patient safety!
Quantum Leaps in Patient Safety
Institute for Healthcare Improvement
Modified from Brian Sexton/Robert Helmreich Aviation Cultural Survey
APPENDIX 2. JHCUSP Staff Safety Survey
Name:
Role:
Date:
Unit:
Please describe how you prevented a patient from being harmed.
Please describe how the next patient in your work area will be harmed.
Please describe how we can prevent this harm by the following:
Preventing the mistake that lead to harm
Making the mistake visible
Reducing the harm should it occur
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