PROJECT PROGRESS 

In September of 2001 the U.S. Agency for Healthcare Research and Quality awarded a five-year, $7 million grant to The UT Houston Medical School to establish The University of Texas Center of Excellence for Patient Safety. The Center consists of five projects plus administrative and technical support units. Each project investigates errors and adverse events from different levels within the healthcare system (individuals, devices, teams, organizations). The projects are united by the theme of translating safety methods from aviation to healthcare. Project leaders, from several institutions, (see below) are experts in cognitive psychology, human-device interactions, medicine, epidemiology, social psychology, quality improvement, and sociology. Co-investigators and Consultants add expertise in nursing, biostatistics, pharmacy, aviation safety/human factors, and 5 medical and nursing specialties. This report reflects activities as of Summer 2005.

The result is an innovative and coordinated approach to understanding and preventing medical errors and adverse events that has led to several important accomplishments.

• Our Center activities, research findings, and products are being disseminated with a website that receives on average over 1,000 visits and over 550 unique visitors per month.
  
  
• Completed by over 100,000 healthcare providers, we continue to disseminate, refine, and analyze data from the UT Safety Attitudes Questionnaire and the UT Safety Climate Questionnaire. Developed in the Memorial Hermann Healthcare System in Houston, healthcare organizations throughout the U.S. and elsewhere are using the surveys. They include the Institute for Healthcare Improvement, Ascension Health, Johns Hopkins Hospital, the United Kingdom’s Intensive Care National Audit Research Centre, Kaiser Permanente, Health Insight, and others. The surveys are also being used by other research groups to measure safety climate/culture. In addition, we are exploring provider attitudes about error reporting and aspects of professional culture relevant to patient safety. Please go to our website for the most recent versions of our surveys.
  
  
• In partnership with the Texas Board of Nursing Examiners and three major teaching hospitals in the Texas Medical Center we created the Healthcare Alliance Safety Partnership (HASP). Based upon an error reporting system in commercial aviation (the Aviation Safety Action Program), it includes: 1) the joint review of error reports by representatives of the Board of Nurse Examiners, hospital nursing leadership, nursing peer review committees, and safety experts; 2) the identification of systems and human performance factors that contribute to errors; and 3) recommendations for systems-based interventions to prevent errors from recurring. HASP seeks to provide protection to the public while also improving healthcare delivery systems.
  
  
• We developed a web-based anonymous close call reporting system (www.utccrs.org) that is currently being used in 10 hospitals. To date, over 450 close calls have been reported via the system and hospitals are using the data to inform improvement efforts, and three Close call Alerts have been sent to participating hospitals, the FDA, and USP regarding close calls due to labeling and packaging.
  

• We have several ongoing efforts to measure and improve team behavior in the operating room and during resuscitation of newborns and trauma victims.
  
  
• We are identifying organizational characteristics of hospitals that can facilitate or hinder a hospital's ability to learn from errors and adverse events.
  
  
• We have explored how the design of infusion pumps can lead to errors, described the device purchasing process in several hospitals, and developed guidelines to help hospitals account for the design of devices during the purchasing process.
  

For additional information contact:

Eric J. Thomas MD, MPH, Principal Investigator
UT Center of Excellence for Patient Safety Research and Practice
UT Medical School
MSB 1.122
6431 Fannin Street
Houston, Tx. 77030

713-500-6702
Eric.Thomas@uth.tmc.edu

Richard Jimenez, Dr.PH cd.
Director
UT Center of Excellence for Patient Safety Research and Practice
UT Medical School
MSB 1.122
6431 Fannin Street
Houston, Tx. 77030

713-500-7081
Richard.Jimenez@uth.tmc.edu

or

UT Center of Excellence for Patient Safety Project Leaders:

Project 2: Device Usability Guidelines

Todd R Johnson, Ph.D.
Associate Professor
School of Health Information Sciences
UCT 690C
7000 Fannin
Houston , TX 77225-0036

713- 500-3921
Todd.R.Johnson@uth.tmc.edu

Project 3: Videotaping to Measure Teamwork

Eric J. Thomas MD, MPH, Principal Investigator
UT Center of Excellence for Patient Safety Research and Practice
UT Medical School
MSB 1.122
6431 Fannin Street
Houston, Tx. 77030

Project 4: Team Training Based on Professional and Organizational Culture

Robert Helmreich, Ph.D.
Professor, Department of Psychology
Human Factors Research
The University of Texas at Austin
Mail Code A8000
Austin , Texas 78712

512- 475-7913
helmreich@mail.utexas.edu

Project 5: Close Call Reporting and Error Reduction

Sharon Martin, M.Ed.
Vice President, Quality Management
UT MD Anderson Cancer Center
1515 Holcombe Boulevard, Box 43
Houston , Texas 77030

713-792-2121
smartin@mdanderson.org

Project 6: Organizational Learning from Error

Michal Tamuz, Ph.D.
Associate Professor
The Center for Health Services Research
University of Tennessee Health Science Center
66 North Pauline, Suite 463
Memphis , TN 38163

Tel. 901-448-3716
FAX 901-448-8009
mtamuz@utmem.edu