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Service Delivery Innovation Profile

Unit-Based Safety Program Improves Safety Culture, Reduces Medication Errors and Length of Stay


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Snapshot

Summary

The Comprehensive Unit-Based Safety Program (CUSP) is a safety culture program that is designed to educate and improve awareness about patient safety and quality of care, empower staff to take charge and improve safety in their workplace, create partnerships between units and hospital executives to improve organizational culture and provide resources for unit improvement efforts, and provide tools to investigate and learn from defects. The unit-based team uses a structured process integrated into an organizational strategic plan, while deferring to the local wisdom of frontline staff members who prevent safety hazards every day. A pre- and post-implementation evaluation of CUSP in two surgical intensive care units at Johns Hopkins Hospital found that the program improved the safety culture and was associated with a reduction in intensive care length of stay, medication errors, and possibly nursing turnover.1 Similar results are seen in other units and other settings (e.g., Michigan intensive care units).2

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes, including perceptions of safety culture, length of stay, medication errors, and nursing turnover.
begin doxml

Developing Organizations

Johns Hopkins Hospital
Baltimore, MDend do

Use By Other Organizations

The program has been rolled out in 170 clinical areas at Johns Hopkins Hospital, and is being used in a national program in which it is combined with an intervention to reduce or eliminate central line–associated bloodstream infections. This national program, called On the CUSP: Stop BSI, is being rolled out state by state in the 50 states, the District of Columbia and Puerto Rico, and also throughout Spain and England.

Date First Implemented

2001
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Patient Population

Vulnerable Populations > Intensive care unit patientsend pp

Problem Addressed

Patient safety and quality of care problems are well documented in the U.S. health care system. These problems lead to medical errors, unnecessary deaths and injuries, and significant excess costs.3 Although many factors contribute to these problems, evidence suggests that organizational cultures do not recognize safety hazards and that there is a lack of comprehension of this shortcoming on the part of executives. In addition, systems reflect deficits in communication and teamwork and work system design, creating safety and quality problems.
  • Role of poor communication: Many sentinel events in health care stem from failures in communication, which is a pertinent element of culture.4
  • Failure of executives to recognize and make safety issues a priority: Perceptions of safety vary widely between health care executives and frontline workers; one evaluation found that executives consistently rate the degree of teamwork and the safety climate within organizations much more highly than do frontline workers.5 As a result, executives may not be aware that additional tools and resources are needed to improve safety. By unifying perceptions and promoting teamwork, comprehensive safety programs may change organizational culture and help ensure that executives and on-the-floor teams work more closely together to improve safety.
  • Poorly designed work systems: Evidence has demonstrated that the systems in which frontline staff work are often poorly designed and can lead to medical errors and patient harm.3 Implementing an improvement tool is one mechanism to redesign a system or process of work that will improve safety and quality of care. Tools are practical, feasible, easily implemented by frontline workers, and become a permanent part of daily practice.

What They Did

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begin pqmxml

Pertinent Quality Measures

Sexton Patient Safety Survey (called the Safety Attitudes Questionnaire)end pqm

Description of the Innovative Activity

The Comprehensive Unit-Based Safety Program (CUSP) is a safety culture program that is designed to educate and improve awareness about patient safety and quality of care, empower staff to take charge and improve safety in their workplace, create partnerships between units and hospital executives to improve organizational culture and provide resources for unit improvement efforts, and provide tools to investigate and learn from defects. Managed by a unit-based team consisting of, at a minimum, a physician, nurse, and administrator, the program uses a structured process that allows it to be integrated into an organizational strategic plan, while also deferring to the local wisdom of frontline staff members who recognize and attempt to prevent safety hazards every day. What follows is a description of key elements of CUSP:
  • Staff education on the basic science of safety: Unit staff receive education on the basic science of safety to help them understand the following: (1) that safety performance is determined by the system in which care is delivered, and, as a result, safety improvement efforts should center on improving systems rather than blaming individuals; (2) that basic strategies for safe design include standardizing work processes, creating independent checks for key processes, and learning when things go wrong; (3) that the principles of safe design apply to both technical issues and teamwork; and (4) that teams make wise decisions when there is diverse and independent input (i.e., health care is a “team sport” that should not be played with a “man down”).
  • Identification of hazards: Teams use many sources to identify potential hazards, including incident reporting systems, liability claims, sentinel events, and morbidity and mortality conferences. One of the most effective and efficient methods used by the teams is to ask staff how the next patient will be harmed on their unit. This question is intended to tap into the knowledge of the people who work on the front lines of care (and therefore know which systems do and do not work), to encourage these individuals to think about ways to fix broken systems on their units and to develop interventions to do so, and to evaluate the impact of these interventions.
  • Partnering of unit with a hospital executive: A hospital executive is assigned to work with frontline staff on the unit to prioritize safety improvement efforts and provide resources to support these efforts. The overall goal of this partnership is to improve culture at the organization level. In addition, by interacting with frontline staff, the executive increases his or her understanding of what is needed to effectively, efficiently, and safely care for patients.6
  • Learn From Defects tool: The Learn From Defects tool provides lenses through which staff can see, learn, and investigate defects (or factors) that contribute to harm or the potential for harm. The tool guides the user through an indepth investigation of one event, in which they design, implement, and evaluate an intervention to mitigate or prevent a future similar event. The tool helps to answer four questions: What happened? Why did it happen? What was done to reduce risk? How do we know that the risk was actually reduced? (This last question has historically received far too little attention.) Each team is asked to learn from one defect per month. To document learning, staff write a brief summary answering the four questions and share it throughout the organization.7
  • Tools to improve teamwork, communication, and the culture of safety: Rather than provide substantial didactic training in teamwork, teams implement any of a variety of tools that are intended to support the practice of teamwork in a safe space. These include the following:
    • Morning briefing: Every morning at shift change and before rounds, physicians and nurses meet to discuss admissions, discharges (including where to start rounds to facilitate discharges), and events that occurred during the night that may pose risks during the day. This briefing is intended to improve communication, teamwork, and the efficiency of unit management.8
    • Daily goals checklist: This checklist is completed on each patient during rounds by the health care team to clarify the care plan for the day. The checklist includes the consideration of potential safety risks for the patient. For example, if the patient has a central venous line, consideration is given as to whether it can be removed to reduce the risk of potential infection.9
    • Culture checkup: This tool is used to structure group discussions within a unit around its culture assessment results and to help the team identify and work on any component (e.g., poor collaboration between physicians and nurses) that has weakened the culture. The culture checkup sparks an open dialogue about the culture of safety, providing a safe venue in which to discuss and resolve problems.10 (See below for more details on the culture assessment results.)
    • Shadowing another profession: This tool allows individual staff members to observe and better understand the roles and responsibilities of other clinical or nonclinical health care disciplines. Teamwork is more efficient and effective when team members are familiar with each other’s role and tasks and when they understand the barriers others face relative to communication and/or collaboration.11
    • Operating room (OR) briefing: The OR briefing is a preoperative dialogue among team members that includes first names and roles, an inventory of equipment and other essential needs, and a plan to guard against potential safety risks.12
    • OR debriefing: An OR debriefing occurs after a procedure to reflect on factors that contributed to, mitigated, or prevented an adverse event or inefficiency during the procedure. Some ongoing debate exists about the cost–benefit ratio of debriefings, particularly in certain situations (e.g., cases that are completed without an adverse event or inefficiency).13
    • eCUSP: eCUSP is a Web-based project management tool that follows the six-step version of CUSP. It is used to manage data collected through the process of identifying safety concerns, developing interventions to rectify potential hazards, and evaluating whether the intervention worked.4
    • Evidence-based practice: Information provided in November 2009 indicates that a new tool was developed and is currently used to identify and eliminate barriers to evidence-based guideline adherence. The purpose of the tool is to assist quality improvement efforts aimed at increasing the reliable use of evidence-based therapies.14
  • Ongoing measurement, feedback, and improvement: Safety culture was assessed using the Safety Attitudes Survey derived from aviation’s Safety Climate Survey.15,16 Results from the baseline and ongoing safety culture assessments, sentinel events, and incident reports are shared periodically with the improvement teams and senior executives to stimulate discussion on how culture may pose a risk to safety and how these risks can be reduced.

Context of the Innovation

CUSP was developed, implemented, and pilot tested at the Johns Hopkins Hospital, which is an academic urban institution serving patients in the East Baltimore area in Maryland. The Johns Hopkins Hospital is a 1,015-bed tertiary care facility that treats approximately 268,224 inpatients annually and attracts patients from across the United States and 126 nations. An attending intensivist who worked in the two ICUs was the innovator and served as the primary catalyst for the program, which was developed in response to the Institute of Medicine’s call to implement initiatives that improve patient safety.3 ICUs were chosen because these units are high-risk areas that are prone to errors that can result in significant consequences when patients are harmed. The units (a 14-bed oncology surgical ICU and a 15-bed surgical ICU that cares for general vascular surgery, trauma, and transplant patients) in the pilot study were chosen because the innovator is an attending intensivist in both ICUs.

Did It Work?

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Results

A pre- and post-implementation evaluation of CUSP in two surgical intensive care units (ICUs) at Johns Hopkins Hospital found that the program improved the safety culture of the units and was associated with a reduction in ICU length of stay (LOS), medication errors, and possibly nursing turnover.1 The success on these units led to the decision to roll the program out to other units and clinical areas throughout the hospital, where safety culture has also improved. The CUSP program has also been implemented in Michigan ICUs, where it has led to improvements in culture.2
  • Improved culture of safety: Results from the safety climate survey show that the percentage of staff reporting a positive safety climate increased from 35 to 52 percent in one ICU and from 35 to 68 percent in the other.1 Information provided in November 2009 indicates that an analysis of CUSP use across the Johns Hopkins Hospital show that the overall percentage of hospital staff reporting a positive safety climate increased from 61 percent in 2006 to 69 percent in 2008, and staff reporting a positive teamwork climate increased from 65 percent in 2006 to 71 percent in 2008.
  • Reduced LOS: CUSP was associated with a reduction in ICU LOS, from 2 days to 1 day on one unit, and from 3 days to 2.3 days on the other unit.1
  • Fewer medication errors: Before implementing the medication reconciliation process that was a part of CUSP, 94 percent of medication orders in one ICU contained errors, whereas 40 percent of charts in the other ICU contained a medication error at transfer. After the intervention, these errors fell to zero on both units.1
  • Reduced nursing turnover: Nursing turnover rates decreased from 9 to 2 percent on one unit and from 8 to 2 percent on the other.1
  • Hospital-wide rollout and continued success: Given the success of CUSP in the two surgical ICUs, this program was rolled out to other units and clinical areas throughout the Johns Hopkins Hospital. Unpublished data show that Safety Attitudes Questionnaire scores on these units have improved since implementation; for example, scores on one unit increased from 35 to 68 percent.

Results From Other Settings

As part of a statewide effort to improve safety, participating ICUs in Michigan implemented CUSP, including the daily goals checklist and two evidence-based interventions for reducing catheter-related bloodstream infections and ventilator-associated pneumonias.2,17,18 This initiative led to improvements in safety culture and a reduction in infections, as described below:
  • Improvements in safety culture: Culture was assessed using pre- and post-implementation teamwork climate scale scores, with either of the following being used as an indicator of improvement: 60 percent or greater consensus that good teamwork exists and/or a 10-point or higher increase in climate scores. (The teamwork climate scale was used because teamwork is recognized as a significant contributor in the safe delivery of health care.) The data show that teamwork climate scores improved significantly across a diverse cohort of ICUs during the year after CUSP implementation. In 2004 (before implementation of CUSP), 17 percent of participating ICUs had a 60 percent or higher consensus among staff that good teamwork existed. By 2005 (after implementation), 46 percent of ICUs had reached the 60 percent or higher figure, and/or achieved a 10-point improvement in its teamwork climate score.2
  • Reduction in infections: The median rate of catheter-related bloodstream infections decreased from 2.7 infections per 1000 catheter-days at baseline to zero at 3 months after implementation of the intervention, and the mean rate decreased from 7.7 per 1000 catheter-days at baseline to 1.4 per 1000 catheter-days at 16 to 18 months of followup.18

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes, including perceptions of safety culture, length of stay, medication errors, and nursing turnover.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Formation of project team: Each unit formed an improvement team consisting of at least a physician, nurse, and the hospital executive. Ideally, teams are multidisciplinary in nature and include as many clinical disciplines as possible that work on the unit. Thus, respiratory therapists, pharmacists, and other staff members were encouraged to join the teams in both ICUs.
  • Obtaining resources: Teams met with individuals who manage the budget (e.g., a nurse manager, unit director, and/or department chair) to introduce the program and secure resources to implement the project.
  • Partnering units with a hospital executive: Teams worked with the hospital executive assigned to the unit to schedule an initial meeting with the improvement team, along with monthly meetings during which the executive conducts rounds on the unit.
  • Assessing baseline safety culture: Baseline assessments of safety culture were conducted on each of the units.
  • Pilot testing, refinement, and rollout: The program was pilot tested in two ICUs. After the pilot test, the program was refined (including a consolidation in the number of program steps) and rolled out throughout the hospital.
  • Developing a new tool: As of November 2009, continued development efforts led to the creation of a new tool that is used to identify and eliminate barriers to evidence-based guideline adherence.

Resources Used and Skills Needed

  • Staffing: At a minimum, a physician and nurse are needed from each participating unit to serve on the improvement team and implement the program. These individuals must dedicate 4 to 8 hours per week to CUSP.
  • Costs: Cost estimates will depend on the resources available for the unit. At Johns Hopkins, the minimum staff time per unit is 4 to 8 hours/week from the safety nurse, 2 hours/week from a coach working in the hospital’s safety and quality department who is trained in CUSP, and 1 hour/month from the hospital executive.
begin fsxml

Funding Sources

Agency for Healthcare Research and Quality; Johns Hopkins Hospital
The pilot project was funded internally by the Johns Hopkins Hospital and the Johns Hopkins University School of Medicine. Now that the program has been adopted throughout the hospital, CUSP funding appears as a line item on departmental and unit budgets. The On the CUSP: Stop BSI program, a national program based on the CUSP initiative, is funded by the Agency for Healthcare Research and Quality (AHRQ) and philanthropic money.end fs

Tools and Other Resources

CUSP Tools for Improvement are available at: http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/improve_patient_safety/cusp
/cusp_tools_improvement.html
. A separate Senior Executive Partnership and Coaching Orientation Handbook will be available on the innovator’s Quality and Safety Research Group Web site in the near future.

More information about CUSP and system redesign is available through AHRQ's Resources on System Redesign. Available at: http://www.ahrq.gov/professionals/systems/system/systemdesign/index.html.

The following articles provide additional background information related to specific components of the CUSP program:
  • Holzmueller CG, Timmel J, Kent PS, et al. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8. [PubMed]
  • Gurses AP, Murphy DJ, Martinez EA, et al. A practical tool to identify and eliminate barriers to compliance with evidence-based guidelines. Jt Comm J Qual Patient Saf. 2009;35(10):526-32. [PubMed]
  • Sexton JB, Helmreich RL, Wilhelm JA, et al. The flight management attitudes safety survey (FMASS). In: The University of Texas Human Factors Research Project, Technical Report 01-01. Austin, TX: The University of Texas; 2001.
  • Sexton JB, Klinect JR. The link between safety attitudes and observed performance in flight operations. In: Proceedings of the Eleventh International Symposium on Aviation Psychology. Columbus, OH: The Ohio State University; 2001.
  • Pronovost PJ, Weast B, Holzmueller CG, et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care. 2003;12(6):405-10. [PubMed]
  • Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. [PubMed]
  • Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32. [PubMed]
  • Gawande A. The checklist. The New Yorker. 2007 Dec 10:1-8.
  • Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: a model for safety improvement. Jt Comm J Qual Saf. 2004;30(2):59-68. [PubMed]
  • Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102-8. [PubMed]
  • Pronovost PJ, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5. [PubMed]
  • Thompson DA, Holzmueller CG, Cafeo CL, et al. A morning briefing: setting the stage for a clinically and operationally good day. Jt Comm J Qual Patient Saf. 2005;31(8):476-9. [PubMed]
  • Thompson DA, Holzmueller CG, Pronovost PJ. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(1):614-8, 561. [PubMed]
  • Sexton JB, Paine LA, Manfuso J, et al. A check-up for safety culture in "my patient care area". Jt Comm J Qual Patient Saf. 2007;33(11):699-703, 645. [PubMed]
  • Makary MA, Holzmueller CG, Sexton JB, et al. Operating room debriefings. Jt Comm J Qual Patient Saf. 2006;32(7):407-10, 357. [PubMed]
  • Makary MA, Holzmueller CG, Thompson DA, et al. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf. 2006;32(6):351-5. [PubMed]
  • Pronovost PJ, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119-29. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

CUSP is designed to be implemented within patient care units rather than at the organizational level; it can be spread unit-by-unit as its effectiveness is demonstrated. This unit-based focus is more manageable and feasible than initiating an organization-wide culture change. The following suggestions can assist with startup:
  • Choose units with room to improve: Select units with low culture scores (if known) or an elevated risk for preventable patient harm, and with a unit leader who will champion the program.
  • Administer baseline questionnaire: Administer the Safety Attitudes Questionnaire before implementation to get a sense of perceptions about safety culture and morale. Gather data from appropriate quality improvement surveys and other sources to compare and analyze.
  • Hold an orientation: Hold a CUSP orientation with the senior executive team and the safety team. (A Senior Executive Partnership Orientation Handbook is included with the CUSP manual.) During the orientation, share information about safety attitudes and other pertinent information.
  • Schedule meetings in advance: Schedule monthly meetings at least 6 months in advance. Post meeting dates and times on the bulletin board along with photos of the key project players and contact information, as this will enhance communication and increase the comfort level of interactions.
  • Increase staff comfort with senior leaders: Have project leaders brief staff on the value of the senior executive partnership. Help staff prepare to discuss issues with their assigned senior executive and collect safety concerns from those who will not be there during senior executive rounds.
  • Streamline the program: Consider streamlining the number and length of the various learning modules and tools. The original CUSP program featured eight modules, but this figure was reduced to six after pilot testing.
  • Ensure adequate time: Allocate adequate time for staff to become familiar with and implement program tools and principles. Four to 8 hours of dedicated training time per week is needed for the first several weeks of the program.

Sustaining This Innovation

  • Hold morning meetings: Conduct morning meetings to reinforce the culture of safety and problem-solving.
  • Reassess culture: Periodically administer the CUSP safety culture reassessment tool and the Safety Attitudes Questionnaire to track changes in morale and perceptions about safety.
  • Provide feedback: Provide frequent unit-specific feedback reports to staff and the senior executive on LOS, medication errors, and other outcome measures of importance.
  • Encourage shadowing: Encourage senior executives, physicians, and nurses to "shadow" each other for a total of at least 4 hours, over one or multiple sessions. Ongoing senior executive and staff dialogue is critical to incorporating lessons learned into the daily routine and spreading the program to other units.
  • Use tools: Use tools such as the daily goals checklist to establish what needs to done for each patient. Use the Healing After Harm tool to help all people involved with a medical error or mishap recover and grow from the experience.

Use By Other Organizations

The program has been rolled out in 170 clinical areas at Johns Hopkins Hospital, and is being used in a national program in which it is combined with an intervention to reduce or eliminate central line–associated bloodstream infections. This national program, called On the CUSP: Stop BSI, is being rolled out state by state in the 50 states, the District of Columbia and Puerto Rico, and also throughout Spain and England.

Additional Considerations

Because CUSP defers to local wisdom, it capitalizes on the fact that frontline caregivers are in the best position to recognize and address potential safety hazards.

More Information

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Contact the Innovator

Peter Pronovost, MD, PhD
The Johns Hopkins University, School of Medicine
Professor, Department of Anesthesiology and Critical Care Medicine
Sr. Vice President for Patient Safety and Quality
Director, Armstrong Institute for Patient Safety and Quality
600 N. Wolfe Street, Administration 328
Baltimore, MD 21287
Phone: (410) 502-6127
E-mail: ppronovo@jhmi.edu

Innovator Disclosures

Dr. Pronovost has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Pronovost PJ, Weast B, Holzmueller CG, et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care. 2003;12(6):405-10. [PubMed]

Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Safety. 2005;1:33-40.

Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-21. [PubMed]

Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. [PubMed]

See the Resources and Other Tools section for a list of additional articles that provide more details on specific components of the CUSP program.

Footnotes

1 Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a Comprehensive Unit-based Safety Program. J Patient Safety. 2005;1:33-40.
2 Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-21. [PubMed]
3 Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America. Washington, DC: National Academies Press; 1999.
4 Pronovost PJ, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119-29. [PubMed]
5 Sexton JB, Pronovost PJ. Safety culture at work: how to measure, improve, and sustain over time. Johns Hopkins Quality and Safety Research Group; 2005 [presentation].
6 Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: a model for safety improvement. Jt Comm J Qual Saf. 2004;30(2):59-68. [PubMed]
7 Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102-8. [PubMed]
8 Thompson DA, Holzmueller CG, Cafeo CL, et al. A morning briefing: setting the stage for a clinically and operationally good day. Jt Comm J Qual Patient Saf. 2005;31(8):476-9. [PubMed]
9 Pronovost PJ, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5. [PubMed]
10 Sexton JB, Paine LA, Manfuso J, et al. A check-up for safety culture in "my patient care area". Jt Comm J Qual Patient Saf. 2007;33(11):699-703, 645. [PubMed]
11 Thompson DA, Holzmueller CG, Pronovost PJ. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(10):614-8, 561. [PubMed]
12 Makary MA, Holzmueller CG, Thompson DA, et al. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf. 2006;32(6):351-5. [PubMed]
13 Makary MA, Holzmueller CG, Sexton JB, et al. Operating room debriefings. Jt Comm J Qual Patient Saf. 2006;32(7):407-10, 357. [PubMed]
14 Gurses AP, Murphy DJ, Martinez EA, et al. A practical tool to identify and eliminate barriers to compliance with evidence-based guidelines. Jt Comm J Qual Patient Saf. 2009;35(10):526-32. [PubMed]
15 Sexton JB, Helmreich RL, Wilhelm JA, et al. The flight management attitudes safety survey (FMASS). In: The University of Texas Human Factors Research Project, Technical Report 01-01. Austin, TX: The University of Texas; 2001.
16 Sexton JB, Klinect JR. The link between safety attitudes and observed performance in flight operations. In: Proceedings of the Eleventh International Symposium on Aviation Psychology. Columbus, OH: The Ohio State University; 2001.
17 Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-32. [PubMed]
18 Gawande A. The checklist. The New Yorker. 2007 Dec 10:1-8.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 24, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 28, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.