EMROAFRO Research Project: Estimating Patient Harm in Developing

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EMRO-AFRO Research ProjectEstimating Patient
Harm in Developing Transitional Countries

• Dr Ross Wilson,
• Dr Ahmed Abdellatif, Dr Philippe Michel, Dr Sisse
  Olsen, Prof Charles Vincent
• International Forum for Quality Safety in
  Health Care Paris 2008

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"I am called eccentric for saying in public that
hospitals, if they wish to be sure of
improvement, must find out what their results
are. Must analyze their results to find their
strong and weak points. Must compare their
results with those of other hospitals...
Such opinions will not be eccentric a few years
hence."
E. A. Codman MD (1869 - 1940)
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Background

• Patient Safety becomes an international issue in
  the 1990s through measurement publication
• Multiple publications on regional and then
  national levels, showing unacceptable levels of
  preventable patient harm (adverse events) not
  just one country
• Beginning of many nationally led efforts to
  improve patient safety

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• Operation 39.3
• Admin system 10.6
• Diagnosis 9.3
• Therapy 8.4
• Drug 6.7
• Procedure 4.3
• Fracture 2.2
• Falls 1.7

• 16.6 of hospitalisations associated
  with AE
• 50 of AEs were preventable
• 18.6 caused permanent disability/death

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CMAJ 2004170(11)1678-86
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Knowledge is the enemy of unsafe care
Harvard Practice Medical Study 1984
Canadian Adverse Event Study 2004
Danish Adverse Event Study 2001
Adverse events in British Hospitals 1999-2001
Utah Colorado Study 1992
French Adverse Event Study 2004
The Commonwealth Fund Survey 2005
Australian Quality in Healthcare Study 1992
Adverse Events in New Zealand Study 2002
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• A worldwide agenda
• In May 2002 the World Health Assembly passed
  resolution WHA55.18, which urged countries to pay
  the greatest possible attention to patient safety
  and requested the Director-General of WHO to
  carry out a series of actions to promote patient
  safety, including
• development of global norms and standards
• promotion of evidenced-based policies
• promotion of mechanisms to recognize excellence
  in patient safety internationally
• encouragement of research
• provision of assistance to countries in several
  key areas.
• The resolution has ensured that the drive for
  safer health care is now becoming a worldwide
  endeavour, bringing significant benefits to
  patients in countries rich and poor, developed
  and developing, in all corners of the globe.

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Dublin 2003

• Expert Advisory Group formed to develop strategic
  and operational direction

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• The Launch of the World Alliance for Patient
  Safety,Washington DC, USA 27 October 2004
• The World Alliance for Patient Safety was
  launched in Washington, DC, on 27 October 2004.
  This was the first time that heads of agencies,
  health policy-makers, patients' groups and the
  World Health Organization came together to
  advance the patient safety goal of "First do no
  harm" and reduce the adverse health and social
  consequences of unsafe health care.
• The Director-General of WHO, Dr LEE Jong-wook,
  launched the Alliance followed by keynote
  speeches by the Chief Medical Officer of the UK ,
  Sir Liam Donaldson, and the Director of Agency
  for Healthcare Research and Quality, Dr Carolyn
  Clancy.

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Leadership

• Essential element

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Key Action Areas

• Research epidemiology of patient harm and
  solutions
• Global Challenge
• Effective role of consumers
• Taxonomy
• Reporting Systems

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Key Action Areas

• Research epidemiology of patient harm and
  solutions
• Global Challenge
• Effective role of consumers
• Taxonomy
• Reporting Systems

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• LONDON DECLARATION
• Patients for Patient Safety
• WHO World Alliance for Patient Safety
• We, Patients for Patient Safety, pledge to help
  create a world in which health care errors harm
  fewer people. We, gathered in London from 27-30
  November 2005 to join together in partnership in
  an effort to reduce the massive burden of
  avoidable harm in health care. Risk and
  uncertainty are constant companions. So we come
  together in dialogue, participating in care with
  providers. We unite our strength as advocates
  for care with less harm in the developing as well
  as the developed world.
• We are committed to spreading the word from
  person to person, town to town, country to
  country. There is a right to safe health care
  and we will not let the current culture of error
  and denial continue. We call for honesty,
  openness and transparency. We will make the
  reduction of health-care errors a basic human
  right that protects human life around the world.
• We, Patients for Patient Safety, will be the
  voice of all patients, but especially of those
  who are now unheard. Together, as partners, we
  will collaborate in
• Devising and promoting programmes for patient
  safety and patient empowerment.
• Developing and driving a constructive dialogue
  with all partners concerned with patient safety.
• Establishing systems for reporting and dealing
  with health-care harm on a worldwide basis.
• Defining best practices that deal with
  health-care harm of all kinds and promote those
  practices throughout the world.
• In honor of those who have died, those who have
  been left disabled and our loved ones today, we
  will strive for excellence, so that all people
  receiving health care are as safe as possible, as
  soon as possible. This is our pledge of
  partnership.
• January 17, 2006

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Key Action Areas

• Research epidemiology of patient harm and
  solutions
• Global Challenge
• Effective role of consumers
• Taxonomy
• Reporting Systems

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More than words?
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Key Action Areas

• Research epidemiology of patient harm and
  solutions
• Global Challenge
• Effective role of consumers
• Taxonomy
• Reporting Systems

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Key Action Areas

• Research epidemiology of patient harm and
  solutions
• Global Challenge
• Effective role of consumers
• Taxonomy
• Reporting Systems

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Knowledge Is the Enemy of Unsafe Care 1st
Meeting on the Global Research Program for
Patient Safety WHO World Alliance for Patient
Safety in Collaboration with AHRQ Washington
November 1, 2005
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Sources of Data on Patient Harm
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Broad based published studies

• Strong (larger) hospital focus
• Obstetric and mental health care often excluded
• necessarily under-estimate the size of the
  problem
• divide into negligence studies with AE rates
  3-4 and improvement studies with AE rates
  around 10
• have reasonable reliability on AE causation, but
  less on preventability
• The harder you look the more you find

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Adverse events and near miss reporting in the NHS
R Shaw, F Drever, H Hughes, S Osborn and S
Williams 1 National Patient Safety Agency,
London, UK2 Hammersmith Hospitals NHS Trust,
London, UK

• Results A total of 28,998 incidents were
  reported including
• 11,766 (41) slips, trips and falls,
• 2514 (9) medication management incidents,
• 2429 (8) resource issues, and 2164 (7)
  treatment issues.
• 138 catastrophic and 260 major adverse outcomes
  were reported.
• Slips, trips and falls (n 11,766) were the
  most common type of incident

Qual Saf Health Care. 2005 Aug14(4)279-83
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Reporting systems?

• Voluntary anonymous reporting
• Does not give prevalence or incidence data and
  hence does not allow prioritisation of
  improvement activities
• Requires new infrastructure
• Is heavily dependent on organisational culture
  (which groups are willing to report)
• Biased toward errors of commission with very
  short latent interval
• But provides unique contextual information
  unobtainable by other sources!

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Observational Study

• An alternative strategy for studying adverse
  events in medical care. Andrew LB, Lancet 1997
  349309-313
• observational study in 3 clinical units in
  tertiary referral hospital
• 17.7 of patients had at least one serious AE
  leading to longer hospital stays
• AE risk increased by 6 for each day in hospital
• 38 of AEs caused by an individual, 10 by
  administrative decisions.

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Observation

• Useful for a defined clinical process
• Injection, blood transfusion, IV cannulation,
  delivery, medication administration
• Useful where there are already agreed standards
  for the process
• Obtaining the data is low cost and low technology
  and training needs
• Analysis can be challenging

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Research Stream Focus

• Using measurement to understand the size and
  nature of patient harm in developing/transitional
  countries
• Development of measurement tools for data-poor
  environments
• Expert Group Ross Wilson, Philippe Michel,
  Sisse Olsen, Charles Vincent, Ross Baker
  supported by Alliance team (Itziar Laritzgoitia,
  Helen Hughes and Martin Fletcher)

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Project Objectives

• To estimate the size and nature of patient harm
  from health care, in developing and transitional
  countries
• To develop methodologies for measuring patient
  harm in data-poor environments
• To provide input into the future development of a
  global patient safety study agenda
• Through measurement, to build local awareness of
  patient safety problems and build will to act to
  reduce patient harm

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Process

• Countries volunteered workshop Cairo Dec 2005
  then agreed to the task
• Generating patient safety interest/activity
  through measurement
• Methodological selection with Philippe Michel,
  Charles Vincent, Sisse Olsen and Ross Baker
• Peak stakeholder group directly connected to
  Ministry
• Ethical approval required in most countries
• Project management and training May 2006
• Reviewing commenced 2006-7 after funding made
  available from World Alliance
• 2008 - Draft reports now being reviewed prior to
  publication

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EMRO December 2005
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Cairo December 2005
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• Commencement of Patient Safety measurement
  project in 9 African countries (EMRO and AFRO)
  December 2005
• Egypt, Tunisia, Morocco, Sudan, Yemen, Kuwait,
  Jordan, Kenya, South Africa
• National teams with representatives from
  Ministry, senior clinicians, health information
  managers etc
• Goal was to build a research collaboration

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Sources of Data on Patient Harm
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Project Scope

• 8 countries Egypt, Jordan, Kenya, Morocco,
  South Africa, Sudan, Tunisia, Yemen
• 26 hospitals (13,500 beds),
• gt15,000 patient records in the database,

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Outcomes so far..

• Health care is causing permanent disability and
  death in developing and transitional countries
• Much of this harm is preventable (75)
• Medical record review is a (surprisingly) viable
  methodology
• Research expertise is variable, but enthusiasm is
  high
• There is agreement to publish results
• There is hunger to use the results to drive
  improvement efforts in all participating
  countries

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30 years old female admitted twice for drainage
of liquor. In last admission, the patient
complained of labour like pain. breech
presentation and pt underwent C/S . Uterus
ruptured and repaired
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35 old woman complained of amenorrhea for 7/12.
Patient diagnosed as diabetes with pregnancy. She
was given insulin to control her blood glucose
level. Patient refused to stay in hospital and
discharged .
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85 years old male admitted through A/E with
history of inability difficult in micturition,
diagnosed as BPH operated on 12/02/2005, and died
the following day
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18 years old girl admitted through A/E with
complaint of headache, fever, convulsion. Patient
received medication and referred to psychiatric
department and later died
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Lessons Learned So Far

• Building a team is essential for completion of
  project as well doing something with the results
• Patient safety can galvanise attention and
  interest such that it leads to huge local effort
• Connecting the project through EMRO to Health
  Ministries in each country is crucial
• Medical record quality is improved by
  promulgation of standards (Egypt Kenya)

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Alexandria 2008
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Future Issues

• How to use the data to drive change locally and
  internationally
• Publication/presentation
• Data ownership
• How much data is enough (and how local) in order
  to inform/energise local efforts
• How to improve medical records (and
  disease/procedure coding)
• Leaving the countries with a measurement tool
  that is locally manageable
• The further development of measurement tools for
  data-poor environments rural and non-hospital

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Pilot testing agreed to in 2007

• To test the feasibility of for measuring patient
  harm in data-poor environments using
• Combining medical record review with structured
  interview with clinical staff
• Using nominal group methods to obtain information
  from a clinical focus group
• Using observation of a clinical interaction
  against agreed standards

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Looking forward by looking back