Transcript Main Title - National Governors Association

PA - PSRS
Medical Liability & Patient Safety:
Pennsylvania’s Experience
NGA Center for Best Practices
Health Policy Advisors
September 10, 2004
PA - PSRS
Background
• Institute Of Medicine Reports
– “To Err is Human – Building a safer health
system” (1999)
– “Crossing the Quality Chasm” (2001)
– “Patient Safety - Achieving a new standard for
care” (2004)
• 44,000 - 98,000 preventable deaths (estimated)
• $29 Billion per year in additional costs
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“Little Progress Seen Since 1999 IOM
Report On Medical Errors”… HealthGrades (2004)
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Why Do Errors Happen?
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Patient Safety
Organization…
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Strategic / Policy Decisions
Charter
• Statute
• Regulation
• Executive Order
Oversight
• Independent
Agency/Board
• Existing Agency
• Licensure Board
Funding
Patient Safety
Organization
Goal
• Learning
• Regulatory
• General Funds
• Assessment /
Fees
• Grant / Other
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Reporting Components
Who Reports
• Acute Care Hospitals
• Long-Term Care
Facilities
• Ambulatory Surgical
Facilities
• Free Standing Clinics
• Pharmacies
Types of Events
By Definition
– Medical Errors
– Near Misses
– Adverse Events
– Serious Events
Pre-Defined List
• Physician’s Offices
– NQF “Never Events”
• Other Licensed Entities
– JCAHO Sentinel
Events
Other
Considerations
• Mandatory vs.
Voluntary
• Individual Identifying
Data
• Data Sharing
• Confidentiality
Provisions
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Pennsylvania’s Approach
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The Medical Care Availability and Reduction of Error
(MCARE) Act of 2002
• Establishes the Patient Safety Authority
• Goal: Reduce and eliminate medical errors by
identifying problems and implementing solutions
that promote patient safety
• Promulgate new reporting requirements for:
Hospitals, Ambulatory Surgical Facilities (ASF’s)
and Birth Centers
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Patient Safety Authority
• 11-member Board appointed by the Governor
and General Assembly consisting of:
– Physician General (Chair), Physician, Nurse,
Pharmacist, Hospital employee, health care
worker, non-health care worker, and 4 other
PA residents
• Established as an independent entity
• Non-regulatory
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Funding Model
• Allows for up to $5 Million a year.
• Assessment of $105/unit based on:
– For Hospitals:
Licensed Beds
– For ASFs:
Licensed Operating Rooms
– For Birth Centers: Licensed Birthing Rooms
• In 2004 and 2005 – assessed $2.5 million or 50% of
authorized amount.
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Reportable Events
• Serious Event (“adverse event”)
– Event that results in patient harm
• Incident (“near-miss”)
– Event that could have injured a patient
• Infrastructure Failure
– Event related to physical plant, facility
systems and criminal activity
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PA - Reporting Components
Who Reports
Acute Care Hospitals
• Long-Term Care
Facilities
Ambulatory Surgical
Facilities
• Free Standing Clinics
• Pharmacies
Types of Events
By Definition
– Medical Errors
Near Misses
– Adverse Events
Serious Events
Pre-Defined List
• Physician’s Offices
– NQF “Never Events”
Other Licensed
Entities
– JCAHO Sentinel
Events
Other
Considerations
Mandatory vs.
Voluntary
No Individual
Identifying Data
• Data Sharing
Confidentiality
Provisions
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Reporting System
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Report Intake
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Report Intake
• 21 Core Questions
– Patient Age / Gender
– Location
– Event type
– Level of harm, contributing factors and root
causes
– Recommendation to prevent future occurrence
• Additional Event Detail Questions
– 15 Major categories, 233 sub categories
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Patient Safety Authority - Clinical Analysis
Incoming
Reports
Triage
Patient Safety
Review Meeting
Analytics
Program
Outputs
PSA Annual
Report
Public Advisories and
Recommendations
Contact with
Individual
Facilities
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Advisory Topics
• Dangerous Abbreviation in Surgery
• Falls Associated with Wheelchairs
• MRI Hidden Risks
• Hidden Sources of Latex
• Use Of Multidose Medication Vials And Latex
Allergy
• Use of X-Rays for Incorrect Needle Counts
• Preventing Wrong-Site Surgery
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Analytical Tools
PA-PSRS
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Harm Score Trend
Facility - Harm Score Trends by Month
# of Reports
80
60
40
20
0
Jan-2004
Feb-2004
Mar-2004
Month
ALL
Event, Harm: Harm Score E, F, G, H
Unsafe Conditions: Harm Score A
Event, Death: Harm Score I
Event, No Harm: Harm Score B1, B2, C, D
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Distribution of Events
Medication
11%
9%
Adverse Drug Reaction
6%
9%
Equipment / Supplies
6%
16%
3%
Fall
Error related to Procedure /
Treatment / Test
Complication of Procedure /
Treatment / Test
Transfusion
21%
28%
Other
Slice 1
Slice 2
Slice 3
Slice 4
8. IV site complication (phlebitis, bruising, infiltration)
9. Extravasation of drug or radiologic contrast
10. Catheter or tube problem
11. Onset of hypoglycemia during care
12. Complication follow ing spinal manipulative therapy
13. Other (specify)
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Event Distribution
Complication of Procedure / Test / Treatment
1. Complication follow ing surgery or invasive procedure
2. Anesthesia Event
2%
2%
2%2%
4% 2%
3. Emergency Department
4. Maternal complication
29%
5. Neonatal complication
12%
6. Nosocomial Infection
7. Cardiopulmonary arrest outside of ICU setting
8. IV site complication (phlebitis, bruising, infiltration)
9. Extravasation of drug or radiologic contrast
12%
10%
10. Catheter or tube problem
11. Onset of hypoglycemia during care
16%
8%
12. Complication follow ing spinal manipulative therapy
13. Other (specify)
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Event Details by Location
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Culture of Learning
The ultimate success of this reporting system will
not be found solely in the data collected. Rather,
improved patient safety will be the result of actions
taken by individual facilities in response to what
they learn through PA-PSRS.
PA - PSRS
PA Patient Safety Authority
www.psa.state.pa.us