November 20, 2005

Dear Colleagues:

I am writing to enlist your help with a new System-wide approach to preventing harm to our patients when we have concerns about equipment or medications.

Several times over the past few years, physicians, nurses and other staff members in individual work areas became concerned that adverse reactions were linked to the equipment they were using, the way the equipment was cleaned or to medications. They were right. Because they acted on their suspicions, they helped launch recalls for a new form of catheter, a new cleaning solution and certain bronchoscope models. You are encouraged to do the same.

If you have a particular concern that fits the profile indicated above, please report it to the Patient Safety Officer for your JHM organization. The list of Patient Safety Officers can be found at http://www.insidehopkinsmedicine.org/operations_integration/contactlist2.pdf. Please note that this should not take the place of reporting specific incidents to the Patient Safety Net or to compliance hotlines. The Patient Safety Officer will work with appropriate experts in your organization. Alert messages will be sent to experts throughout JHM by Margaret Garrett, senior counsel of the Johns Hopkins Health System, working with the Department of Operations Integration. Those receiving the messages will be expected to communicate the alert to key staff in their organization and to report findings back to Ms. Garrett.

Sharing such concerns swiftly among appropriate staff throughout Johns Hopkins Medicine should have a number of benefits. These include heightened awareness of the potential for harm in similar situations elsewhere at JHM, more rapid collection of data confirming or reputing the suspected cause and more rapid reporting to manufacturers and regulatory agencies of confirmed problems.

Thank you for your help with this important effort to enhance communication across Johns Hopkins Medicine.

Sincerely,
Judy A. Reitz, Sc.D.
Executive Vice President, The Johns Hopkins Hospital
Vice President, Quality Improvement, Johns Hopkins Medicine