Implementing and Evaluating a Program of Patient Safety

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Implementing and Evaluating a Program of Patient
Safety
Successful Reporting Systems as the Foundation

• Katherine Jones, PhD, PT
• Anne Skinner, RHIA
• Gary Cochran, PharmD
• Keith Mueller, PhD

Supported by AHRQ Grant 1 U18 HS015822
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Objectives

• Explain the role of voluntary reporting systems
  in a program of patient safety
• Identify the characteristics of successful
  reporting systems
• Identify information necessary for systematic
  data collection in a medication error reporting
  program
• Understand how the NCC MERP Taxonomy of error
  severity provides a language to describe errors
  in the context of a system

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The Problem

• The problem is not bad people the problem is
  that the system needs to be made safer . . .
  Voluntary reporting systems are an important part
  of an overall program for improving patient
  safety and . . . have a very important role to
  play in enhancing an understanding of the factors
  that contribute to errors.
• To Err is Human Building a Safer Health System

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Reporting is the foundation of a culture of safety

• Any safety information system depends crucially
  on the willing participation of the workforce,
  the people in direct contact with the hazards. To
  achieve this, it is necessary to engineer a
  reporting culturean organization in which people
  are prepared to report their errors and
  near-misses.

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Components of Safety Culture
Reason, J. Managing the Risks of Organizational
Accidents. Hampshire, England Ashgate
Publishing Limited 1997.
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Reporting is supported by just, flexible, and
learning cultures

• The willingness of workers to report depends on
  their belief that management will support and
  reward reporting and that discipline occurs based
  on risk-takingthere is a clear line between
  acceptable and unacceptable behavior
  workersorganizational practices support a just
  culture.
• The willingness of workers to report depends on
  their belief that authority patterns relax when
  safety information is exchanged because managers
  respect the knowledge of front-line
  workersorganizational practices support a
  flexible culture.

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Reporting is supported by just, flexible, and
learning cultures

• Ultimately, the willingness of workers to report
  depends on their belief that the organization
  will analyze reported information and then
  implement appropriate changeorganizational
  practices support a learning culture.
• The interaction of practices that support
  reporting, just, flexible, and learning cultures
  produces an informed, safe organization that is
  highly reliable.
• The organizational beliefs and practices
  associated with these components of culture are
  assessed by the AHRQ HSOPSC.

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Characteristics of Successful Reporting Systems

• Nonpunitive reporters do not fear punishment as
  a result of reporting
• Confidential identities of reporter, patient,
  institution are never revealed to a 3rd party
• Independent reporting is independent of any
  authority who has the power to discipline the
  reporter
• Expert analysis reports are analyzed by those
  who have the knowledge to recognize underlying
  system causes of error
• Timely reports are analyzed promptly and
  recommendations disseminated rapidly
• Systems-oriented recommendations focus on
  systems not individuals
• Responsive those receiving reports are capable
  of disseminating recommendations

Leape, LL. (2002). Reporting of adverse events.
NEJM, 347, p. 1636.
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MEDMARX

• MEDMARX is an anonymous medication error
  reporting program that subscribing hospitals and
  health systems participate in as part of their
  ongoing quality improvement initiatives.
  Nationally, data from MEDMARX contributes to
  knowledge about the causes and prevention of
  medication errors. Over 870 hospitals and health
  systems have submitted more than 1.3 million
  medication error records to MEDMARX. Analyses of
  voluntary medication error reports from large
  patient safety databases, such as MEDMARX, can
  identify system sources of error and lead to the
  establishment of safe medication practices.

Stevenson JG. Medication errors Experience of
the United States Pharmacopeia. Jt Comm J Qual
Safe 200531(2)106-111.
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www.MEDMARX.com
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Systematic Data Collection in Medication Error
Reporting

• Description of the error
• Error severity based on the outcome to patient
• Phase of the medication use process in which the
  error originates
• Type of the error
• Cause of the error
• Contributing factors to the error
• Information about the drug(s) involved

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NCC MERP Taxonomy of Error Severity

• A capacity to cause error
• B error occurred, did not reach patient
• C error reached patient, no harm
• D error reached patient, monitoring and
  intervention required
• E temporary harm requiring intervention
• F temporary harm requiring initial or prolonged
  hospitalization
• G permanent harm
• H intervention required to sustain life
• I error contributed to or resulted in death

http//www.nccmerp.org/pdf/taxo2001-07-31.pdf
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Reporting Error Severity
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Reporting Where Errors Originate
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Reporting Types of Errors
Jones et al. (2006). http//www.unmc. edu/rural/do
cuments/pr06-08.pdf
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Reporting Causes
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Reporting Contributing Factors
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What we heard about using MEDMARX as the
foundation for reporting in Critical Access
Hospitals

• Before the project, we just counted errors. We
  never went past the type of error.
• Using MEDMARX increased reporting because people
  had more knowledge that what we are doing is
  intended to make the system safer.
• Using the lingo of MEDMARX, errors got broken
  down into categories that even the board could
  understand so they were more open to thinking
  about allocating money for an automated
  dispensing system.

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What we heard continued

• Without the language of errors associated with
  MEDMARX, all we could talk about was who did it
  and not what happened and why. MEDMARX created a
  standardized process that allowed us to collect
  more information. The use of MEDMARX and its
  graphs and charts contributes to the perception
  of errors as having a system source.
• Because we were able to visualize the system
  through the graphs and charts, we could
  communicate to staff and take action.