Process Improvement Drives Patient Safety

After carefully recording and examining all adverse events that occur in the operating room, pediatric cardiothoracic surgeons, including Pirooz Eghtesady, MD, PhD, in red cap, have implemented several new quality improvement measures.

Washington University pediatric cardiothoracic surgeons at St. Louis Children’s Hospital have adopted principles used in high-reliability industries such as aviation and nuclear power to improve patient safety in the operating room.

In a recent study, Pirooz Eghtesady, MD, PhD, section chief, and other pediatric heart surgeons recorded all adverse events in the operating room, even seemingly insignificant ones. Initially, they were written on note cards after surgery and placed in a locked box, functioning much like an airplane’s “black box” flight recorder. Later, the researchers reviewed a video recording of the procedure to capture a detailed report of events. The purpose was to apply the “preoccupation with failure” concept, used in high-tech industries to look at microsystems and intervene when minor failures can lead to adverse outcomes.

“If an antibiotic doesn’t come to the operating room on time, it’s probably not just a random event, but rather a reflection of the state of the operating-room environment that day, or perhaps some other downstream decision that someone has made,” says Eghtesady, the Emerson Chair in Pediatric Cardiothoracic Surgery. “We want to see if we can dig deeper and figure out what it means, and by doing that, make the system better.”

The study turned up correlations between incidents; for example, patient instability more often occurred in tandem with problems such as equipment malfunctions and patient injury sustained in the operation. The observations resulted in quality improvement measures. A “one person speaks at a time” rule was initiated in the prebypass period, when most communication failures were recorded, and a manufacturer improved the quality of its product when presented with data that showed repeated failure.

Eghtesady and patient safety officers at the medical school are considering recording incidents using risk management software that is comprehensive and easier to use.

“We could then record adverse events in a database that would allow us to more easily identify patterns and opportunities to improve patient care and patient experience,” says Eghtesady.


Families of children who undergo heart or lung surgery at St. Louis Children’s Hospital keep close tabs on their child’s progress in the operating room, thanks to a smartphone app called EASE (Electronic Access to Surgical Events), shown at right. Through it, the care team delivers real-time updates in the form of photos, videos and text messages. This is in addition to phone calls and a nurse practitioner speaking in person to the family during surgery. Families have given the app a 99 percent satisfaction rate.

Orlando Petrucci, MD, PhD, who started the second-busiest heart transplant program in Brazil, has joined the Section of Pediatric Cardiothoracic Surgery after nine years on the faculty of the University of Campinas in Sao Paul, Brazil. Petrucci, who is well-versed in both adult and pediatric heart surgery, will direct the adult congenital heart program.

Section Chief Pirooz Eghtesady, MD, PhD, has worked with a multidisciplinary team at St. Louis Children’s and a medical instruments company to develop a communications platform to help inform intensive care unit (ICU) staff about incoming surgical patients while those patients are still undergoing surgery. The platform will allow care providers in the operating room to speak with and transmit images to doctors and nurses in the ICU during surgery.

The lung transplant team has received approval from the Washington University Institutional Review Board and the U.S. Food and Drug Administration to test a lung perfusion device to evaluate whether the device can improve lung function to allow marginal lungs to be used in pediatric transplant.