If the transmission of the deadly Ebola virus from a now-deceased patient to one of his nurses occurred because of a "protocol breach," what does that say about the general state of patient and caregiver safety in hospitals across the country?
The whole world is watching. If we can't get this right with regard to Ebola, the virus that already has caused more than 4,000 deaths in western Africa and one in the U.S., a person can reasonably ask what's going on the rest of the time, in the day-to-day of intensive-care units everywhere. Are doctors and nurses doing everything possible to prevent harm? Are they following protocols?
The fact is, medical errors happen frequently, causing infections and complications and hundreds of deaths every day. That's from the doctor in charge of safety at Johns Hopkins, one of the world's leading hospitals.
Peter Pronovost has been beating the drum for patient safety for years, insisting, for instance, that a simple protocol for using central-line catheters can cut hospital-acquired infections significantly and save lives.
His checklist — the Pronovost Protocol, I call it — has been shown to be effective. Implemented in the intensive-care units of 70 hospitals across Michigan a decade ago, it virtually eliminated bloodstream infections.
In 2008, Time magazine named Pronovost one of the most influential people in the world and the MacArthur Foundation gave him one of its "genius" grants. He's an anesthesiologist and the Hopkins senior vice president for patient safety. He continues to push the country's doctors and nurses to avoid the avoidable by doing simple things, like washing their hands or wearing sterile masks, when they insert or remove catheters.
You'd think such things were standard in ICUs by now. But they're not. "Breaking protocol is the norm in health care," Pronovost said Monday. Hand-washing, he added, ranges from 50 percent of the required time in some hospitals to 90 percent in others.
In July, Pronovost told a congressional committee that preventable health care deaths still occur about 600 times daily across the country, and he says that was a conservative estimate.
So Pronovost was not altogether surprised to hear that the transmission of Ebola in Texas Health Presbyterian Hospital was due to a "protocol breach."
That's what the director of the Centers for Disease Control and Prevention called it. Dr. Thomas Frieden said the CDC will investigate how the nurse, who was in full protective gear, contracted the Ebola virus from Thomas Eric Duncan, who died Wednesday. "At some point," Frieden said, "there was a breach in protocol. That breach in protocol resulted in this infection."
Some experts have questioned Frieden's statement, saying American nurses and other health care workers have not been adequately trained in the approach to Ebola patients.
Pronovost, the go-to guy when it comes to ICU protocols, did not comment specifically on what happened in Dallas — details of the breach have not been made public, and the CDC is still investigating — but he listed three fundamentals of hospital safety: preventing mistakes that could cause infection; preventing harm if a mistake occurs; and minimizing harm if a mistake occurs.
With regard to Ebola, that means following a checklist, like the one from the CDC, to prevent the spread of the virus — wearing protective clothing, double-gloving, limiting the use of needles, etc.
"One of the things we have to do is break the myth that clinicians are infallible," Pronovost said Monday. "We're human, we're going to make mistakes. The key is anticipating mistakes."
That means, he said, having a plan for preventing harm if there's a breach — by disinfecting clothing, for instance — and a plan for harm reduction if things get to that point, as they have with the nurse in Dallas.
There's another layer to the issue of patient safety in U.S. hospitals, and it arose at least briefly when the staff at Texas Health Presbyterian initially failed to recognize Duncan as the nation's first Ebola case and sent him home.
According to The Dallas Morning News, there were questions about what the hospital knew about Duncan and when.
That gets us to Pronovost's second area of concern: the lack of integration of patient information in the new electronic records systems hundreds of hospitals have been installing in recent years.
Even at Hopkins, Pronovost told Congress, there are new buildings and state-of-the-art machines, but they lack the computer engineering that would make patient care more collaborative, more efficient and less dangerous.
"We bought the best ICU, operating room and emergency settings possible," Pronovost said. "Yet the best is backed with scores of pieces of equipment that do not communicate."
In other words, the state of the art is not good enough because it's not connected — too many monitors and devices that do not speak to each other.
"Engineers at the [Johns Hopkins] Applied Physics Lab are appalled at how under-engineered medicine is," Pronovost said.
That leaves the system prone to human errors, and in the 21st century that's so unnecessary.
Dan Rodricks' column appears Tuesday, Thursday and Sunday. He is the host of "Midday" on WYPR-FM.