To begin, we adopted the useful policy of many safety systems, such as the one used in the aviation industry. All reports of errors, from all sources, are channeled through my office; in my role as medical director, I chair the patient safety committees. These committees provide a means of analyzing the event, and they help to direct process-improvement efforts designed to eliminate the root causes of errors with the goal of reducing the likelihood of similar events in the future.

At UPMC, we have found that the most effective way to identify and address medical errors is through a well-researched procedure called root-cause analysis. This procedure is used to determine appropriate remedies by identifying the factors most likely to put patients at risk. UPMC has categorized these risk factors into the following domains:

  • human
  • non-human (e.g., equipment, technologies, and so forth)
  • controllable or uncontrollable
  • information management
  • environmental
  • leadership
  • communication

The Joint Commission on Accreditation of Healthcare Organizations advocates this process to analyze sentinel events, and we employ it for adverse outcomes of all types: deaths, adverse drug reactions, medication errors that do not result in serious outcomes, events reported to the risk management department, and incidents discovered “through the grapevine.” The investigation is not designed to be punitive; until the root causes are elucidated, we do not accept the veracity of the initial report. Great pains are taken to maintain a “blame-free environment.”

In addition to investigating these routine sources, we conduct root-cause analyses on all “Condition C” crisis situations. Procedures for reacting to Condition C were instituted several years ago at UPMC as a standardized response to a medical emergency. The response is identical to that used in cases of cardiac arrest, at which time a critical-care team is summoned immediately to the patient’s bedside. In contrast to the standard approach to patient crises at teaching hospitals, whereby a chain of command often delegates responsibility to the least experienced members of the care team (i.e., interns), Condition C allows anyone, regardless of stature or reason, to call for help without the fear of blame or penalty.
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To encourage and facilitate a standardized call for clinical help, UPMC developed a set of criteria for initiating Condition C. The criteria include an acute loss of consciousness; new-onset difficulty in breathing; sudden collapse; seizures; and sudden loss of movement of the face, arm, or leg. These criteria were published on laminated cards and were repeatedly distributed to all hospital personnel. After Condition C was implemented, the number of fatal cardiac arrests dropped from 2.6 per 1,000 admissions to 1.6. On average, 33 deaths have been prevented annually.