National Patient Safety Partnership Aims to Save Lives with Data

February 2015
Topics: Decision Analysis, Decision Support (General), Informatics, Public Health (General), Health Services Administration 
Every year, as many as 400,000 Americans die because of avoidable medical errors in hospitals and other health facilities. MITRE is partnering with a team of hospitals to expedite the elimination of avoidable errors through data sharing and analysis.

Everyday across the United States, people have friends or family members who enter the hospital with non-life-threatening issues and are injured or die because a caregiver made a mistake or the patient acquired an infection that didn't respond to antibiotics. Even in the best hospitals, caregivers may administer the wrong medications, fail to prevent hospital-acquired infections, or overlook life-threatening events among the din of false alarms from an ever-increasing number of medical devices.

In fact, every year in this country it's estimated that as many as 400,000 Americans die because of avoidable medical errors in hospitals and other health facilities. This makes medical errors the third leading cause of death in the United States.

Once viewed as unavoidable risks, such errors are now widely recognized as systemic failures of the healthcare system. Currently hospitals use a variety of approaches to address this issue. However, in many cases improvement is incremental and new practices spread slowly across the country because teams work in isolation with limited data collection and analysis capabilities.

From Data to Decisions

Seeking a solution to this critical problem, MITRE researchers began looking for ways the healthcare industry could systematically reduce errors on a large scale. One idea was to take a successful cross-industry data-sharing approach that we had developed in the aviation domain and apply it to healthcare.

The inspiration for the National Patient Safety Partnership came from the aviation industry, which established a public-private partnership, known as Aviation Safety Information Analysis and Sharing (ASIAS), to proactively identify and analyze safety issues before accidents occur. Since 2007, MITRE has served as the trusted steward to safeguard and analyze sensitive aviation-industry safety data. This collaboration—which includes airlines, government agencies, and aircraft manufacturers—has led to numerous safety findings and solutions.

The National Patient Safety Partnership

Translating the ASIAS concept to healthcare, MITRE is now working with leading pediatric hospitals to demonstrate the value of a National Patient Safety Partnership (NPSP) to expedite the discovery and elimination of causes of avoidable patient safety events. The NPSP is assembling a rich set of data, ranging from electronic medical records to medication administration to vital signs from physiologic monitors.

MITRE is developing advanced tools and methods for combining and analyzing this data to model the interplay between patient conditions and treatment events. The goal is to automate the identification of indicators that a problem could occur.

Our capabilities in integrating multiple data sources and applying analytics to data on a large scale are essential to the success of the NPSP. As a trusted third party, we will safeguard this rich data repository and provide the tools for clinical leaders to view the patterns, trends, and factors that correlate with safety issues and develop interventions for preventing future incidents. With the NPSP tools and data, clinicians will be able to rapidly assess the impact of these interventions in reducing errors.

"Something like this has never been done before in healthcare, and we believe it could transform the state of knowledge of patient safety in such a way as to systematically reduce medical errors and other harm to patients," says Joy Tobin, MITRE's chief of health informatics and NPSP leader. "Can you imagine if the aviation industry were losing 50 airliners in accidents every week? Because that's the equivalent of what's happening in healthcare today.

"The potential impact from the partnership could be dramatic—from lives saved and injuries avoided, to millions, if not billions, in reduced costs."

Piloting the Approach with Pediatric Hospitals

For the NPSP launch, Tobin and her team elected to focus on pediatric hospitals because a high level of collaboration and trust already exists within this community, which has facilitated the sharing of sensitive data.

MITRE identified three leading pediatric hospitals to participate in this new approach: Boston Children’s Hospital, Children's National Health System, Washington, D.C., and Cincinnati Children’s Hospital and Medical Center.

"When I learned of MITRE's patient safety initiative, I knew that we wanted to be a part of it," said Sandra Fenwick, Boston Children's president and CEO. "At Boston Children's, patient safety is already one of our most critical priorities and we pride ourselves on doing an excellent job of keeping our young patients safe. But this collaboration with the National Patient Safety Partnership is a way to take safety to the next level."

Together, the four partners have each brought deep expertise in a variety of disciplines—including big data analytics, clinical informatics, physiologic monitoring, and medication management—to the challenge. They also bring a deep commitment to improve patient safety and prevent fatalities.

The group's early results are promising. For example, an initial analysis of medication errors identified potential errors in the medication ordering process. A study of alarm fatigue identified potential mitigation strategies that would reduce unnecessary alarms so that clinicians can focus more on patient care.

Expanding Outward to the Broader Health Community

Looking ahead, the partners are committed to sharing the insights learned from their analyses with the broader healthcare community. They also plan to broaden the types of data collected and analyzed by recruiting electronic health record vendors and medical device manufacturers to join NPSP.

"In the future, we could explore a broad range of health industry topics through NPSP’s data and MITRE's powerful analytics," said Tobin. "There is almost no end to the types of issues we can explore—and help resolve—with this type of partnership. We are focusing on safety first because the opportunity to prevent avoidable deaths and injuries in healthcare settings clearly has the greatest urgency."

—by Twig Mowatt and Beverly Wood

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