The on-line Wall Street Journal posted an interview with Dr. Peter Pronovost, a leading expert on patient safety and quality improvement. He created a 5-step checklist that hospitals can use to prevent bloodstream infections in the ICU. Michigan hospitals used the checklist and saw their infection rates decrease by 66%. As a result, many other hospitals are starting to use the checklist. Dr. Pronovost talks about how a checklist is important but there is also the need to change the culture in order to have successful implementation of the checklist. For example, a nurse should feel comfortable telling a doctor that he/she needs to wash his/her hands before inserting a central line, and the doctors should accept the fact that nurses will be telling them what needs to be done in some cases. As Dr. Pronovost says, when everyone looks at this as an issue of patient safety, the resistance to the use of the checklist goes away. Health Care For All and the Consumer Health Quality Council are advocating for legislation that would require hospitals in Massachusetts to use checklists such as this one to prevent patient harm. HCFA and the Consumer Council also successfully advocated for legislation last session requiring public reporting of infection rates at hospitals. The first public report with infection rates by hospital will be issued in early 2010. In the WSJ article, Dr. Pronovost says “Right now, these deaths are invisible. If every hospital had to publicly report their rates of infection, I guarantee you this problem would be solved.” If the checklist legislation passes, in addition to the public reporting that will start happening next year, then Massachusetts will have the opportunity to be the first state to make the problem of infections go away.
Deborah W. Wachenheim
Health Quality Manager
