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Preventing Harm in the ICU—Building a Culture of Safety and Engaging Patients and Families

Thornton, Kevin C. MD1; Schwarz, Jennifer J. MS, ACNP-BC2; Gross, A. Kendall PharmD, BCPS, BCCCP2; Anderson, Wendy G. MD, MS3; Liu, Kathleen D. MD, PhD1,3; Romig, Mark C. MD4,5; Schell-Chaple, Hildy RN, PhD2; Pronovost, Peter J. MD, PhD5,6; Sapirstein, Adam MD5,6; Gropper, Michael A. MD, PhD1; Lipshutz, Angela K. M. MD, MPH1; for the Project Emerge Collaborators

doi: 10.1097/CCM.0000000000002556
Concise Definitive Review

Objective: Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts.

Data Sources: Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched.

Study Selection: Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations.

Data Extraction: Our group determined by consensus which resources would best inform this review.

Data Synthesis: A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded.

Conclusions: Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

1Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.

2University of California San Francisco Medical Center, San Francisco, CA.

3Department of Medicine, University of California San Francisco, San Francisco, CA.

4Johns Hopkins University School of Medicine, Baltimore, MD.

5Armstrong Institute for Quality and Patient Safety, Johns Hopkins Medicine, Baltimore, MD.

6Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Additional Project Emerge Collaborators are listed in Appendix 1.

This work was performed at Department of Anesthesia and Perioperative Care, University of California San Francisco and Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, San Francisco, CA.

Supported, in part, by grant from the Gordon and Betty Moore Foundation.

The authors have disclosed that they do not have any potential conflicts of interest.

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