Improving Patient Safety in Healthcare

“With support from AHRQ, I’ve been able to influence the way that healthcare leaders think about safety. The Agency gave me the credibility to establish the largest human factors research center in a U.S. health system, and funded development of tools that have improved patient safety in a meaningful way.”

For more than 30 years, safety-critical industries, like aviation and nuclear energy, have relied on a safety science and human factors engineering approach to reduce accidents. This approach is dedicated to understanding the factors, such as the work environment and technology, that influence peoples’ actions, then redesigning them for optimal safety and overall system performance and reliability. Despite the benefits, the healthcare industry has lagged behind in implementing these engineering methods, missing an opportunity to accelerate progress in patient safety.

A trained safety scientist and human factors engineer, Rollin J. “Terry” Fairbanks, M.D., M.S., noticed this gap when he first entered the medical field. He has dedicated his career to applying a human factors engineering approach to healthcare systems. Currently the Senior Vice President and Chief Quality and Safety Officer and an emergency physician at MedStar Health in the Baltimore and Washington, D.C. region, Dr. Fairbanks received funding from AHRQ to increase knowledge and create tools that help healthcare providers reduce patient safety events in high-risk settings of care, where the complexity of the system and the fragility of the patients creates a greater risk for adverse events. According to Dr. Fairbanks, however, the impact of AHRQ’s support goes beyond these project successes. He credits the Agency with starting a research career that led to the development of a $40 million human factors research center, enabled him to mentor dozens of highly specialized safety scientists, and gave him, “a greater platform by which to impact the perspective and approach to safety among healthcare leaders.”

Dr. Fairbanks, who also is a professor of emergency medicine at Georgetown University School of Medicine, received a 2-year AHRQ grant in 2005 to evaluate an emergency medicine clinical pharmacist program to avoid adverse drug events in emergency department (ED) patients. For this study, Dr. Fairbanks evaluated over 10,000 ED cases for adverse events, and interviewed ED physicians and nurses to understand their perception of the value of the clinical pharmacist, learn which pharmacist services they found helpful, and gather ideas on ideal ways to structure an ED pharmacist program.

Based on this study, Dr. Fairbanks and his team created a toolkit to help introduce similar pharmacist programs to other EDs. In 2007, Dr. Fairbanks expanded his work by serving as a mentor for a program developed by the American Society of Health-System Pharmacists called the “Patient Care Impact Program.” Using this program, over 100 U.S. hospitals have developed and implemented an emergency pharmacist role in their institutions.

Continuing with his focus to improve patient safety in complex and high-risk healthcare environments, Dr. Fairbanks received a 4-year AHRQ grant in 2012 for a research project that aimed to decrease the rate of avoidable fetal injury and unnecessary cesarean deliveries by improving interpretation of electronic fetal heart monitoring. Dr. Fairbanks’ objective was to validate the effectiveness of serious game-based simulation training—­a computer-based program that simulates real-world scenarios for both entertainment and learning purposes—by comparing it to “classic” (manikin-based) simulation lab training. Dr. Fairbanks and his colleagues found that there was not a significant difference in overall performance between the manikin-based and game-based groups, a finding that helped facilitate the acceptance of serious game-based training in medical education, particularly for those without access to large simulation centers.

In 2014, Dr. Fairbanks was awarded a 5-year AHRQ grant to study and develop processes to boost decisionmaking and problem solving in a range of high-risk healthcare environments. As Dr. Fairbanks describes, hospital EDs are high-risk, fast-paced environments involving coordination and shared decision making by staff, who care for multiple patients simultaneously. Over the last couple of decades, health information technology has improved handwriting legibility issues, data sharing capabilities, and historical information access. However, according to Dr. Fairbanks, these advances also have led to serious unintended consequences, such as wrong-patient orders, increased cognitive workload, and decreased shared awareness.

His mixed-methods study included observations, interviews and focus groups with emergency medicine providers to identify shared information needs; communication methods, strategies, and barriers; and factors affecting successful communication. These efforts led him and his team to develop an integrated patient-focused status display, tested for workplace usability, to support ED clinicians’ communication and situation awareness regarding a patient’s health status and progress through their ED plan of care. This tool is an innovative approach to information visualization in emergency medicine, with patient-focused information in a user-centered design.

Having gained experience through these AHRQ-funded projects, Dr. Fairbanks established the National Center for Human Factors in Healthcare to facilitate the infusion of safety science and human factors engineering principles in healthcare delivery. The Center was started with seed funding from the MedStar Institute for Innovation, and Dr. Fairbanks credits AHRQ grants with giving him the credibility to receive this support. With several AHRQ-funded investigators and mentees of Dr. Fairbanks, the organization quickly became the largest human factors center embedded in a health system in the United States and has led to major changes in the healthcare industry. Through the Center, Dr. Fairbanks and his colleagues have helped to develop future leaders in human factors engineering. He has trained a number of emerging health services researchers who have received AHRQ grants, and several researchers have gone on to lead their own patient safety initiatives in different healthcare systems. One of Dr. Fairbanks early mentees, Raj Ratwani, Ph.D., is an AHRQ investigator and now a mentor himself to several colleagues at the National Center for Human Factors in Healthcare, many of whom also have received AHRQ funding. “AHRQ funding not only has allowed me to develop my research program, it also has helped me spur change in other health systems by mentoring other researchers who are now making a significant international impact, often supported by AHRQ grants themselves,” said Dr. Fairbanks.

Dr. Fairbanks is Founding Director Emeritus for the National Center for Human Factors in Healthcare. He is a fellow in the Human Factors and Ergonomic Society and the American College of Emergency Physicians. He also is on the faculty for the Institute for Healthcare Improvement. Dr. Fairbanks has been listed several times by Becker’s Hospital Review as an expert leading the field of patient safety.

Principal Investigator: Rollin J. Fairbanks, M.D., M.S.
Institution: MedStar Health
Grantee Since: 2005
Type of Grant: Various 

Related AHRQ Resources

• Impact Case Study.
• PSNet.
• Toolkit for Improving Perinatal Safety.

Return to AHRQ Grantee Profiles