Patient Safety and Harm

1
Patient Safety and Harm

• Michael ODell, MD, MSHA
• Chief Quality Officer, NMHS
• Residency Director, NMMC Tupelo

2
Harm

• Unintended physical injury resulting from or
  contributed to by medical care that requires
  additional monitoring, treatment or
  hospitalization, or that results in death.

3
Disseminated Disease of Medical Progress?

• Very few people would care to challenge the fact
  that our present day knowledge and capabilities
  have been productive of more good for mankind
  than harm. Can we, however, fully justify doing
  more harm to our patients simply because we can
  now do more good?
• Seckler SG, Spritzer RC Disseminated Disease of
  Medical Progress. Arch Int Med 1966 117447-450

4
Harm Detected by Three Methods None Perfect
5
Baseline Measures

• IHI Trigger Tools
• Look for things like
• Return to surgery
• Less than 30 day readmit
• Post-op infection
• Use of a rescue med e.g. Narcan

6
Preventable?

• No attempt made in harm tracking to ascertain
  whether an event was preventable
• An adverse event is, by definition, harm

7
Severity Rating

• Based on National Coordinating Council for
  Medication Error Reporting and Prevention (Only
  Categories E-I used)
• Category A Circumstances or events that have the
  capacity to cause error
• Category B An error that did not reach the
  patient
• Category C An error that reached the patient but
  did not cause harm
• Category D An error that reached the patient and
  required monitoring or intervention to confirm
  that it resulted in no harm to the patient
• Category E Temporary harm to the patient and
  required intervention
• Category F Temporary harm to the patient and
  required initial or prolonged
• hospitalization
• Category G Permanent patient harm
• Category H Intervention required to sustain life
• Category I Patient death

8
Never Events / Hospital Acquired Conditions 2007
9
Patient Safety
10
Agenda Item 2 and 3 Harm Measures and Composite
CMS No MCC/CC 2009 CMS No MCC/CC proposed

• 14. Maternal Blood Transfusion
• 15. 3rd or 4th Degree Perineal Laceration
• 16. Normal Newborn Transfer to a Higher Level of
  Care
• 17. Complication Associated with Anesthesia
• 18. Postoperative physiologic and metabolic
  derangement CMS Poor gly control
• 19. Postoperative Wound Dehiscence
• 20. Postoperative Respiratory Failure
• 21. Retention of a Foreign Object
• 22. Air Embolism
• 23. Blood Incompatibility
• 24. Hospital Acquired Injuries
• 25. Hospital Acquired Pressure Ulcers
• Wrong Site Surgery
• Surgical site infections ortho
• Surgical site infections - bariatrics
• DVT PE following certain ortho px
• Poor Glycemic Control

1. Hospital Acquired Benzodiazepine Associated
Event 2. Hospital Acquired Narcotic Associated
Event 3. Hospital Acquired Poisoning 4.
Hospital Acquired Clostridium Difficile 5.
Hospital Acquired Staphylococcus Aureus
Septicemia 6. Hospital Acquired Central line
assoc Blood Stream Infections 7. Hospital
Acquired Catheter Associated Urinary Tract
Infections 8. Ventilator Associated Pneumonia 9.
SSI Mediastinitis after Coronary Artery Bypass
Graft (CABG) 10. Uterine Rupture 11. Birth Trauma
birth weight gt 2500 grams or 37 weeks 12. Birth
Trauma birth weight lt 2500 grams or 37 weeks 13.
Return to OR/LD
11
Is Medicine Getting Better?
12
Lake WoBeGon and its hospital

• Where all the women are strong, the men are good
  looking, and the children are above average
• Memorial Lady of the Lake Hospital-
• where all the physicians are strong, the nurses
  are good looking, and the patient outcomes are
  above average

13
So-----

• Improving care involves
• The organization being organized to
  systematically improve care
• The medical staff and licensed professionals
  their moral duty and accountability to improve
  care
• Medical staff and professionals must possess the
  competence and character to perform their
  function
• A major function of the organization is to
  reinforce and affirm the competencies and
  character of the medical staff and licensed
  professionals
• Organizational Resources, Personal Competency,
  Mutual Ongoing Demand for Excellence,
  Organizational Training and Support

14
Is All Harm Due To Error?

• No!
• Error may certainly cause harm
• But not all error results in harm
• Near misses
• Error without effect

15
Can Harm Occur Without Error?

• Yes!
• Even well designed systems have unintended
  consequences
• Flawless execution of a process may still result
  in harm

16
Why Focus on Harm - I

• Overall patient safety goal is to reduce patient
  injury or harm
• Medical errors are numerous
• Many have potential to be harmful
• Numerous reports show that error is often not
  linked to injury

17
Why Focus on Harm - II

• Focus on error tends to focus on individual
• Focus on harm tends to focus on systems
• Focus on systems more likely to improve care and
  outcomes
• Focus on systems reduces fear of punishment and
  encourages cooperation with patient safety efforts

18
Commission v. Omission

• Harm Measures focus on active care (Commission)
• Excludes Omission (substandard care)

19
Preventability

• Harm Measures assess all adverse events
• No attempt to determine preventability during
  chart reviews
• Adverse Event Harm

20
IHI Global Trigger Tools

• Institute for Healthcare Improvement
• Use of manual chart review to study harm as a
  result of active medical care
• Use trigger methodology to search for harm
• Trigger event often associated with harm
• If trigger present, chart reviewed further to
  determine if harm occurred

21
Triggers and Modules

• Cares
• Medication
• Surgical
• Intensive Care
• Perinatal
• Emergency Department

22
Example Cares Module Triggers

• Transfusion of Blood or Use of Blood Products
• Abrupt gt25 drop in Hemoglobin or Hematocrit
• In-hospital stroke
• Code or Arrest
• New Onset Dialysis
• Positive Blood Cultures
• Full Measures http//www.ihi.org/IHI/Results/Whi
  tePapers/IHIGlobalTriggerToolWhitePaper.htm

23
Conduct of Chart Review

• Closed records gt 30 days post discharge and with
  completed discharge summaries and coding
• Three person review team
• Two record reviewers
• Clinical background
• Knowledge of contents of institutions medical
  record
• Knowledge of how care is provided in the hospital
• Physician to authenticate consensus

24
Conduct of Chart Review II

• Reviews performed on a sample of discharges
  (including deaths)
• 20 records every two weeks
• Record reviewed only for presence of triggers
• If trigger found, then review of pertinent
  sections of the chart is conducted for presence
  of harm
• Many triggers may be found but there will
  likely be far fewer episodes of harm
• If an adverse event happens to be found without a
  trigger record it it is an adverse event

25
Conduct of Chart Review III

• Was there an adverse event?
• Defined as unintended harm from the viewpoint of
  the patient
• Would you be happy if this happened to you? If
  no, then there was harm.
• Was the event part of the natural progression of
  the disease or was it a complication of
  treatment. Harm should be the result of medical
  care interventions.
• Was the event an intended consequence of care? A
  permanent scar following surgery is not harm.
• Psychological harm is excluded

26
Conduct of Chart Review IV

• Adverse events present on admission are still
  adverse events
• Only significant events should be recorded
• For our purposes at NMMC we tag as hospital or
  other

27
Adverse Event to Trigger Ratio
28
NCC MERP

• National Coordinating Council for Medication
  Error Reporting and Prevention
• Harm Measures adapt this classification
• Only those classifications associated with harm
  are included
• E Temporary harm to patient that requires
  intervention
• F Temporary harm to patient that requires
  initial or prolonged intervention
• G Permanent patient harm
• H Intervention required to sustain life
• I Patient death

29
Presenting to the Board

• Issues-
• Lay persons
• Focus
• On impact on patients
• On impact on institution

30
Patients Harmed v Not Harmed
31
Harm Type Pareto
32
Where does Harm Occur?
33
Length of Stay by Harm Type

• Uniformly Increased

34
Event Associated Triggers (All)
35
Event Associated Triggers (Hosp)
36
If Harm, How Often?
37
Process for Reducing harm

• Patient Safety Council
• Use of Medical Staff Peer Review where
  appropriate
• Discussions with outside agencies (e.g. Nursing
  Homes)

38
Questions?