Documentary features Pittsburgh work in catching medical errors
Inside UPMC Presbyterian, researchers used genetic sequencing to identify 10 patients sick with the exact same strain of a hospital-acquired infection. They then used a machine learning algorithm to track the paths of those patients, figuring out that nearly all of them had visited the same interventional radiology lab — where they found improper sterilization procedures, driven in part by a faulty training video distributed by the equipment manufacturer.
Immediately, they alerted the radiology lab and the manufacturer, stopping the distribution of that video to improve patient safety both at Presby and beyond.
That program at Presby — and several other initiatives nationwide — are featured in a documentary premiering this week at the Cleveland International Film Festival.
The movie, “The Pitch: Patient Safety’s Next Generation,” focuses on new technology to reduce medical errors and improve patient safety.
“It’s not easy to find technology solutions to patient safety problems,” said Mike Eisenberg, the documentary’s director. “They exist, they’re out there, but they aren’t in broad daylight like other technology solutions are.”
The documentary, funded by the Pittsburghbased Jewish Healthcare Foundation, will also be shown in May through the JFilm Jewish film festival in Pittsburgh.
Eisenberg’s previous film, “To Err is Human,” also tackled the topic of preventable medical mistakes. That film, released in 2018, received widespread acclaim but had its distribution curtailed by the COVID-19 pandemic. The film was inspired by the work of Eisenberg’s late father, John M. Eisenberg, director of the Agency for Healthcare Research and Quality and a pioneer in medical quality improvement.
Despite leaders such as John M. Eisenberg soundingthe alarm about medical errors since the 1990s, they are still a significant issue in hospital admissions. One 2023 study found that one in four patients experiences adverse effects in a hospital, and that one in four of those is preventable.
Because of his previous work in the field, The Jewish Healthcare Foundation reached out to Eisenberg about directing this documentary focusing on the role of technology.
And while there was no
mandate to focus on work going on in Pittsburgh, the story about the program at UPMC Presby was a natural fit.
That program, called the Enhanced Detection System for Healthcare-Associated Transmission (EDS-HAT), was developed jointly with researchers at the University of Pittsburgh and Carnegie Mellon University.
Lee Harrison, director of the Center for Genomic Epidemiology at Pitt, and Artur Dubrawski, research professor of computer science at CMU, are both interviewedin the documentary.
During its trial at UPMC between 2016 and 2018, EDSHAT was able to uncover 99 outbreaks associated with hospital-acquired infections, and was able to identify at least one transmission route in 65% of those clusters. Traditional methods of infection prevention over that time were only able to identify 15 of those infection cluster outbreaks.
Researchers estimated that the technology could have prevented 63 infectious disease transmissions, had it been running in real time over that period. Since the study, UPMC has implemented it in their hospitals.
“It was the perfect story we wanted to tell for this film,” said Eisenberg. “Everything fell into place beautifully.”
The movie also features other efforts to use technology to improve patient safety, including a doctor in East Lansing, Mich., reducing the use of anesthesia by using virtual reality, a health center in Toronto using a GE command center model, and a start-up company led by a young former medical student in San Jose, Calif. trying to improvematernal mortality.
“There are so many stories to tell in patient safety and they just don’t get told very often,” said Eisenberg. “In terms of what’s next, that’san untold story.”