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IMPROVING PATIENT CARE

QUALITY GRAND ROUNDS

Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.

Funding for the Quality Grand Rounds series is supported by the California Health Care Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.

Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit

Peter J. Pronovost, MD, PhD; Albert W. Wu, MD, MPH; and J. Bryan Sexton, PhD

15 June 2004 | Volume 140 Issue 12 | Pages 1025-1033

Intensive care is one of the largest, most expensive, and complex components of U.S. health care. Errors and the resulting adverse events are, however, common in intensive care units (ICUs). Theories about errors in high-risk environments, developed by aviation and other industries, provide insight into why ICUs are prone to errors. Complex systems—of which ICUs are certainly an example—are breeding grounds for errors because interdependent components interact in unexpected ways. To achieve favorable outcomes, ICUs require that many processes occur in sequence. For example, patients are cared for by many providers with varying levels of expertise across several disciplines, and these providers use highly sensitive and potentially dangerous technologies and medications. Such complex systems require careful planning, excellent teamwork and communication, and designed redundancies to recheck for proper care processes. This paper provides a practical framework for improving patient safety.

For a list of questions and answers from the Quality Grand Rounds conference, see the Appendix.

Author and Article Information

From The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and The University of Texas, Center of Excellence for Patient Safety Research and Practice, Texas.

Grant Support: By the Agency for Healthcare Research and Quality (grant number U18 HS11902). Funding for the Quality Grand Rounds series is supported by the California Healthcare Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Peter J. Pronovost, MD, PhD, Quality & Safety Research Group, Johns Hopkins University, 901 South Bond Street, Suite 318, Baltimore, MD 21231.

Current Author Addresses: Drs. Pronovost and Sexton: Quality & Safety Research Group, Johns Hopkins University, 901 South Bond Street, Suite 318, Baltimore, MD 21231.

Dr. Wu: Johns Hopkins University, 624 North Broadway, Hampton House, Room 633, Baltimore, MD 21205.

This article has been cited by other articles:

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				A. W. Wu, A. K. M. Lipshutz, and P. J. Pronovost Effectiveness and Efficiency of Root Cause Analysis in Medicine JAMA, February 13, 2008; 299(6): 685 - 687. [Full Text] [PDF]

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