Improving Safety: Developing Safety Metrics and Improving Error Reporting. Petra Khoury, Pharm D Adnan Tahir, MD
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1 Improving Safety: Developing Safety Metrics and Improving Error Reporting Petra Khoury, Pharm D Adnan Tahir, MD
2 Learning Objectives List Prevalent patient safety issues reported within hospitals Identify Methods to effectively Target, Review and reduce errors Using an error-reduction event model, evaluate how to improve the workflow process within the hospital Describe how key Safety Metrics can be developed and used to improve processes
3 Background In late 1999, the Institute of Medicine (IOM) published the sentinel report, To Err is Human: Building a Safer Health System, that captured the US Nation's attention. The report highlighted the scope of medical errors and raised safety concerns
4 What s the Harm in healthcare? Safety Issues Hospital-acquired infections (MRSA, VRE, C. Diff, VAP/pneumonia, UTI) Number of cases/yr including deaths 2.2 Million Pressure Ulcers 257,000 Medication Errors 1.5 million Falls and Fractures 100,000 Deep Vein Thrombosis 46,764 Surgical errors (wrong-site/wrong side, objects left behind) Total 2,892 4 Million 1-in-3 hospital patients is accidentally harmed every year in U.S. hospitals. 100,000 deaths/ yr ~~ 10 jumbo jet crashes each wk
5 Adverse Event Capture Audience Poll: What percentage of error-related event are reported at your institution? a. 90% b. 70% c. 50% d. 30% e. Not sure
6 Improve Data Capture Psychological safety vs Accountability: what s the right point on a balance beam? Psychological safety: is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes Staff education, non-punitive culture
7 Comfort Zone Learning Zone Motivation & Accountability Apathy Zone Anxiety Zone Psychological Safety
8 Improve Data Capture Review Reporting Process including the reporting forum Proactive screening program: - Chart review: medications, labs, radiology - Adopt trigger tools: IHI Global tool for measuring Adverse Events
9 IHI Global trigger tool Captures adverse events related to active delivery of care Triggers: - Care related: blood transfusion, code arrest; acute dialysis, positive blood culture, doppler for DVT, drop Hb or Hct by 25%, pt fall, PU, HAI, in-hospital stroke, restraints - Medication related: PTT>100; INR>6; Glucose<50; Vit K admin; narcan admin; flumazenil admin
10 IHI Global trigger tool - Surgical related: reoperation; post-op ICU transfer; PACU intubation; change in OR plan; intra/post-op death - Intensive Care: pneumonia; readmission to ICU; reintubation - Perinatal related: 3 rd /4 th degree laceration; platelet < 50,000; blood loss> 500ml for vaginal delivery - ED related: readmission within 48hrs; time in ED> 6hrs 90 AE/ 1000 patient days or 40 AE/ 100 admissions
11 Improve Data Capture Define metrics and adopt a Safety Plan Encourage reporting: annual education: Hospital care is complex and depends on the interaction of so many disciplines Provide feedback Suggestion Box
12 Data Collection and Review System: - Build Standard data entry fields - Avoid free text Define who will review the Data: - Patient Safety Committee - P&T - PIC - Nursing Quality council ** Share the data **
13 Look at trends: Reduce Events based on risk= consequence X likelihood Adopt a standard system for risk level and action requirements Leadership and management safety rounds: feedback; observations Adopt recommendations from Safety societies: ISMP, AHRQ
14 Error- Reduction Models FMEA: Failure mode effect analysis PDSA: Plan- Do- Study- Act
15 PDSA: Plan- Do- Study- Act
16 Measurements Not everything that can be counted counts. Not everything that counts can be counted
17 Joint Commission International Patient Safety Goals 1. Identify patients correctly Patient identification before blood transfusion Patient identification before medication administration 2. Improve effective communication Reporting of critical test results (read-back) 3. Improve the safety of high-alert medications 4. Ensure correct-site, correct-procedure, correct-patient surgery 5. Reduce the risk of healthcare associated infections 6. Reduce the risk of patient harm resulting from falls Pharmacy interventions in KCl orders Time out and skin marking Laterality documentation in the patient medical record Compliance with hand hygiene guidelines Surgical site infections in clean surgery Patient falls by unit Injury falls
18 Patient Identification Goal 1: Improve the accuracy of patient identification. Use at least two patient identifiers when providing care, treatment and services.
19 Improve Communication Goal 2: Improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis.
20 Medication Safety Goal 3: Improve the safety of high-alert medication
21 Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery Goal 4: Conduct a pre-procedure verification process. Mark the procedure site A time-out is performed before the procedure.
22 Goal 5: Health Care-Associated Infections Reduce the risk of health care-associated infections. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines
23 Reduce Falls Goal 6: Reduce the risk of patient harm resulting from falls.
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