Transcript Pursuing Perfection - Alpert Medical School

Pursuing Perfection:
Preventing Harm to our Patients
Mary Reich Cooper, M.D., J.D.
Senior Vice President and Chief Quality Officer, Lifespan
Asst. Professor, Medicine,
Alpert Medical School of Brown University
February 5, 2011
My first deposition: I was not yet a J.D.
Equitable
Efficient
Timely
Effective
Effective
Patient-Centered
Agenda:
Institute of Medicine Approach to Quality
SAFE
IOM 2001
Crossing the Quality Chasm
Safe Care: The Past Decade
 Safety Surveys
 Medical
 Safety Culture
Errors/Adverse Events
 Near Misses & Good
Catches
 Unsafe Conditions
 RCAs
 FMEAs
 PSOs
 Safety Rounds
 Crew Resource
Management
 Team Training
 Just Culture
Event # 1
You are the doctor in charge.
Monday 11 am
You are in the
OR
Your P.A. is
in the ED
Condition
deteriorates
81 yo M
comes into
ED
Patient
transferred to
OR
Event Occurs
Responsibility,
Accountability,
Culpability?
RIH Events: 2004 -2011
 2007
 January: wrong side neurosurgical drainage of
subdural hematoma bedside
 July: wrong-side drainage of subdural
hematoma operating room main
 November: wrong side neurosurgical drainage
of subdural hematoma bedside
 2009
 May: wrong-side palate children’s operating
room
 October: wrong site finger ambulatory
operating room
Rhode Island Hospital
Surgery Cases
Surgery Errors/100,000 Patient Days
Statewide Wrong Site Errors/100,000 Pt Days*
RI, MA, and MN
1.6
1.361
1.4
1.2
1
0.8
0.7402
0.7403
RI-2 (CY2009)
MA (FY2008)
0.6
0.4
0.2961
0.2
0
RI-1 (FY2008)
MN (CY2008)
*Source: MA and MN from annual statewide reporting based on NQF SRE's. Includes surgical events on the wrong body part, the wrong patient, and the wrong procedure. Excludes surgical events for
foreign objects and intra/post surgical deaths. MA data from FY2008; MN data from CY2008. RI data from Projo article, "Another wrong-site surgery at Rhode Island Hospital" by Felice Freyer Saturday
Oct. 24th, 2009. RI-1 rate based on FY2008 count of 2 (Nov 23, 2007 and Sept 19, 2008). RI-2 rate based on CY2009 count of 5 (1 at RIH in May, 2009; 2 at Kent in June, 2009; 1 at TMH in June,
2009; 1 at RIH in Oct, 2009) with FY2008 patient days (patient days for CY2009 not available).
The National Experience
Source: Seiden S, Barach P. Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events. http://archsurg.ama-assn.org/cgi/content/full/141/9/931. Acessed
October 27, 2009.
Retained Foreign Object
HOSPITAL
Wrong Surgical Procedure
Health Adverse Event Reporting
Wrong Patient Surgery
Massachusetts Department of Public
Wrong Site Surgery
2008
TOTAL
MASS GENERAL HOSPITAL
3
0
1
1
4
BETH ISRAEL DEACONESS MED CTR/EAST
3
0
0
1
4
BOSTON MED CTR CORP MENINO PAVILION
0
0
0
4
4
UMASS MEMORIAL
0
0
0
3
3
ST VINCENT HOSPITAL
0
0
0
4
3
BAYSTATE MEDICAL CENTER
1
1
0
1
3
BRIGHAM & WOMEN'S HOSPITAL
1
0
0
2
3
RHODE ISLAND
RHODE
ISLANDHOSPITAL
HOSPITAL
00
00
00
0
0
0
Source: Commonwealth of Massachusetts Department of Public Health 2008 Report: Serious Reportable Events in Massachusetts Acute Care Hospitals
http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/sre_acute_care_hospitals.pdf
0
HOSPITAL
Retained Foreign Object
Health Adverse Event Reporting
Wrong Site Surgery
Massachusetts Department of Public
Wrong Surgical Procedure
2009
TOTAL
MASS GENERAL HOSPITAL
3
1
6
10
BRIGHAM & WOMEN'S HOSPITAL
2
0
3
5
BAYSTATE MEDICAL CENTER
2
0
2
4
BETH ISRAEL DEACONESS MED CTR
1
1
2
4
JORDAN HOSPITAL
1
1
2
4
TUFTS MEDICAL CENTER
1
0
3
4
RHODE ISLAND
HOSPITAL
RHODE
ISLAND
HOSPITAL
2
2
0
0
0
0
22
Source: Commonwealth of Massachusetts Department of Public Health 2009 Report: Serious Reportable Events in Massachusetts Acute Care Hospitals
http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/sre_report_2009.pdf
2005
4
0
2
19
0
2006
3
1
0
18
0
2007
3
2
4
17
1
2008
5
0
1
14
0
Total
15
3
7
68
1
Public Health Adverse Event
Reporting
All Hospitals
Source: Connecticut Department of Public Health Legislative Report to the General Assembly: Adverse Event Reporting October 2008
http://www.ct.gov/dph/lib/dph/government_relations/2008_reports/oct2008_adverseeventreport_finaldraft.pdf
Intra-Op Death ASA-1
Wrong Patient Surgery
Retained Foreign Object
Wrong Site Surgery
Connecticut Department of
Wrong Surgical Procedure
2005-2008
Briefing Required
Time Out Required
Debriefing Required
• Surgeon identifies patient, procedure,
site/side mark, (confirmed with consent by
RN) and discusses the plan for surgery
• Initiated by attending surgeon
• Initiated by attending surgeon
prior to leaving the Operating
Room
• Identify new team member(s) and role
• Discussion Points (as applicable):
- Antibiotic status
-
Glycemic control
Beta-blockers
Medications needed on field/irrigation
Patient position
Equipment/implants required for procedure
Patient safety considerations
Blood
DVT prophylaxis
Allergies
Special considerations (hearing deficit, language
barrier, friable skin, risk for pressure ulcer,
pacemaker, etc.)
- X-rays/PACS up on screen
- Lab work
- Consult(s)
• Patient identification, procedure
site/side (confirmed with consent by
RN through read back)
• Surgeon’s initials (if applicable) on
procedure site/side visible after
prepping and draping
• Confirmation by team that the
mark (If applicable) is visible
• Does anyone have any concerns?
• Are we ready to proceed?
• Specimen labeling and
destination communicated
• Confirmation of procedure
performed
• Discussion Points (as applicable):
- Post-op plan of care (ICU bed,
ventilator, etc.)
- Patient temperature
- Wound classification
- Review of what worked well and what
could have been done differently
- Identify any instrument/ equipment
concerns
• Does anyone have any concerns?
•Surgeon asks are we ready to begin?
Revised 06/18/10
Wrong Site Surgery – Are They Preventable?
 Wrong-side/wrong-site , and wrong patient adverse events
(WSPE) are more common than previously reported. Based on
the several available databases these adverse events have
been occurring steadily for years without significant attention
or evidence of reduction in prevalence.
 The data support widespread underreporting of these adverse
events.
 At a minimum, assuming 100% of cases are reported, our
extrapolation of data from Florida predict that there would be
1321 cases in the United States annually.
 However, multiple studies have demonstrated that the
compliance of physicians in reporting has ranged from 5% to
50% of events thus predicting a WSPE incidence of 2600
events in the United States annually.
Source: Seiden S, Barach P. Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events.
http://archsurg.ama-assn.org/cgi/content/full/141/9/931. Acessed October 27, 2009.
Arch Surg 2006;141;931-9
Event # 2
You are the doctor in training.
Wednesday 2 am
You are covering
Radiology at
night
The tech has
noticed an
artifact
You stop the
MRI
The patient had
surgery earlier
that day
You confer with
the surgical
resident
Event Occurs
Responsibility,
Accountability,
Culpability?
Your mistake, Paper’s headlines
Minnesota Experience
Source: Minnesota Department of Health: Adverse Health Care Events Reporting System: What have we learned? 5-year REVIEW (2003-2008)
http://www.health.state.mn.us/patientsafety/publications/2010ahe.pdf
Mandated Reporting:
http://www.jointcommission.org/sentinel-event-statistics/ accessed 1/14/2011
Medicare Says It Won’t Cover Hospital Errors
•Sign In to E-Mail or Save This
By ROBERT PEAR
Published: August 19, 2007
WASHINGTON, Aug. 18 — In a significant policy change,
Bush administration officials say that Medicare will no longer
pay the extra costs of treating preventable errors, injuries and
infections that occur in hospitals, a move they say could save
lives and millions of dollars…..
HAC: Preventable Complications
1. Object left in surgery
2. Air embolism
3. Blood incompatibility
4. Catheter Associated Urinary Tract Infection
5. Pressure Ulcers
6. Catheter Associated Blood Stream Infection
7. Surgical Site Infection – Mediastinitis; Orthopedic;
Bariatric
8. Injuries
9. Glycemic Control (Blood Sugar)
10. DVT (Clots)
Event # 3
You are the medical student.
Saturday 2 pm
Admission to
your unit:
76 yo F
Your resident is
putting in a line
Your patient
has been in the
ED for 12 hours
You are asked
to do admit
H&P
Everyone is in a
hurry to start
treatment
You see this….
Event Occurs
Responsibility,
Accountability,
Culpability?
Why Is This Picture Important?
Stage I Pressure Ulcer
(Bed Sore)
Why are Pressure Ulcers Important?
 The annual cost for treating pressure ulcers in the
US ranges between 2.2 and 3.6 Billion dollars
 Rhode Island begins public reporting on hospitalacquired pressure ulcer assessments in 2009
 CMS stopped paying hospitals for Stage 3 and 4
hospital-acquired pressure ulcers in October 2008
 Over the past 10 years, we have paid out 1.5
million dollars in claims brought for patients who
developed pressure ulcers
 NDNQI requires pressure ulcer reporting
 Pressure ulcers are no longer “nursing” indicators
Event # 4
You are a doctor on the team.
Wednesday 7 pm
You are eating
dinner
The nurse tells
you your
patient has pain
The patient
stops breathing
You order
Morphine 5 mg
You reverse it
with Naloxone
Event Occurs
Responsibility,
Accountability,
Culpability?
On a given day at Lifespan Hospitals…
 85 medication errors (actual and prevented) will be reported
 39 actual medication errors will be detected and reported
 46 medication errors will be prevented
 MAK will prevent…
 6 “Wrong patient” medication related errors (bring up a patient record and
scan the patient’s bracelet, not a match)
 6 “Wrong drug,” Wrong dose,” “Wrong route” errors (have correct patient
record that matches the patient’s bracelet, but scan of medication reveals
drug error)
 30 prescribing errors will be prevented
 5 excessive doses of medication will not be given
 1 drug allergy will be avoided
Innovation
Electronic Medical
Records
Innovation
Smart Pumps
Innovation
Patient
Identification
Event # 5
You are a doctor on the team.
Tuesday 10 am
You are on
rounds
The patient
spikes a fever
Your attending
asks you to
talk about BSI
The patient
has a SC
catheter
Sentinel
Event?
Event Occurs
Responsibility,
Accountability,
Culpability?
National Healthcare Safety
Network (NHSN)
Rhode Island ICU Collaborative
ICU Collaborative Lifespan Performance- Comparative Data - 2006-quarter 2 2010
BSI (goal is zero) - infections/1000 line days*
VAP (goal is zero) - infections/1000 vent days*
VAP Bundle Composite
(goal is >90%- higher is better)
Lifespan - ICU
Newport Hospital ICU
0.00
0.00
0.00
%chg 0609
0.00
0.00%
Rhode Island Hospital ICCU
0.00
0.00
0.00
3.23
0.00%
Rhode Island Hospital 5ISCU
3.01
1.15
1.03
0.53
Rhode Island Hospital CCU
1.96
0.00
0.00
Rhode Island Hospital CTIC
1.48
0.00
1.94
2.54
Rhode Island Hospital ICTU
6.41
0.00
2.10
Rhode Island Hospital INC
1.78
1.46
0.85
0.48
Rhode Island Hospital MICU
1.96
1.66
1.00
1.51
Rhode Island Hospital RICU
3.39
1.84
1.50
Rhode Island Hospital SICU
4.79
1.34
Rhode Island Hospital TICU
4.49
Miriam Hospital CCU
Miriam Hospital CVTI
Miriam Hospital CVTS
Miriam Hospital ICU
2006
Statewide Aggreggate
Mean
Statewide Aggreggate
Median
Aggregate
numerator/demominator
Lifespan Aggregate mean
Lifespan Aggregate
numerator/demominator
RIH Aggregate mean
RIH Aggregate
numerator/demominator
TMH aggregate mean
TMH Aggregate
numerator/demominator
2007
2008
2009
Q1
Q2
Q3
Q4
2010 2010 2010 2010
0.00 0.00 2.89
2006
2007
2008
%chg 0609
4.85
8.26%
2009
Q1
Q2
Q3
Q4
2010 2010 2010 2010
0.00 0.00 17.39
2006
2007
2008
76.26
93.96
99.10
***0
***0
***0
%chg 0609
96.86 27.01%
2009
4.48
2.90
1.76
0.00 0.00 0.00
0.00
0.00
0.00 0***
0.00%
0.00 0.00 0.00
-82.39%
0.00
0.00
0.00
0.00
0.00
0.00 0***
0.00%
0.00
0.00
0.00
***0
***0
***0
0.00 -100.00%
0.00
0.00
0.00
0.00
1.63
0.00
2.05 205.00%
0.00
0.00
0.00
17.14
38.55
75.32
75.73 341.83%
71.62%
0.00
0.00
0.00
0.67
2.47
2.39
3.24 383.58%
90.29
0.00 -100.00%
0.00
0.00
0.00
0.00
0.00
0.00 0***
-73.03%
1.82
5.38
0.00
7.65
2.36 11.45 10.96
-22.96%
3.25
2.18
2.69
0.94
0.30
0.63
0.80
-76.40%
0.00
2.16
4.96
0.67
1.71
1.61
1.97
1.59
-66.81%
2.00
0.00
0.00
6.08
4.50
2.22
5.83
4.90
9.13%
0.00
6.36
3.95
7.86
0.00
2.24
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
3.76
4.00
3.12
1.03
2.99
1.80
1.24
1.16
1.69
0.69
1.06
1.64
-81.65%
-73.50%
-47.44%
0.00
0.00
1.27
0.00
0.00
1.67
0.00
0.00
1.49
2.41
1.34
1.24
1.34
-44.40%
0.00
0.00
0.00
2.34
***0 N/A
***0 N/A
99.28 99.28 92.69
0.00 0.00 0.00
0.00
2.90
72/
24860
2.96
52/
17539
3.36
21/
6252
65/ 64/
64/
36213 37337 39049
1.56
1.37
1.25
12/
9475
-56.90%
38/ 35/
33/
24332 25499 26322
1.46
1.56
1.46
5/
6514
-50.68%
25/ 29/
28/
17154 18643 19234
2.06
1.90
13/ 7/
6307 6445
0.72
0.77
-78.57%
5/
6930
15/
9006
1.58
13/
8706
1.72
0.00
0.00
4.33
72.12
24.00
80.62
0.00
0.00
0.00
***0
***0
***
43.27%
7.17
4.33
6.51
27.15
18.60
86.28
91.08 235.47%
93.22 93.22 94.03
2.19 132.98%
1.13
1.25
2.87
73.95
52.41
62.10
79.96
8.13%
68.33 68.33 98.05
3.29 391.04%
3.09
3.05
6.92
71.34
47.58
67.26
94.89
33.01%
93.97 93.97 100
7.31
5.61
-7.73%
7.37
4.80
2.83
56.67
72.29
87.40
94.91
67.48%
98.83 98.83 92.75
8.50
7.44
7.14
-9.16%
14.55
9.33 13.38
64.26
50.44
80.38
88.70
38.03%
95.26 95.26 93.66
2.87
4.10
7.30
0.00 -100.00%
67.40
97.44
92.91 115.82%
100.00 96.77 93.75
11.98
0.00
0.00 0***
9.71
11.20
4.01
4.13 12.92 14.68
6.71
2.99
2.50
3.36
3.28
3.40
2.47
1.61
2.27
-100.00%
51.18%
-77.68%
-15.21%
4.67
3.33
4.03
4.26
92/
62/
68/
72/
19702 18637 16864 16902
1.02
5/
4899
10/
4556
46/
40/
51/
56/
14634 14491 13195 13147
0
0/
1419
0.00
0/
1521
0.75
1/
1340
-2.99%
119/
99/
89/
91/
29625 29428 27122 26765
10/
10/
6349 5798
2.19 1.95
8/
4112
0.00
43.05
0.00
***0 N/A
0.00
0.00
98.46 100.00 100.00 ***0
0.00 0.00
1.79 0.00
2.91 *2.19
6.90
2.06
4.90
76.68
49.31
61.64
72.69
71.81
69.21
98.95
98.30
79.99
97.12
95.43
87.26
26.66%
93.53%
41.56%
0.00 0*
2.83
67.41
70.55
87.4
90.63
34.45%
3.14
10.06
42/
4175
2.76
5.79
20/
3457
3.87
5.16
16/
3101
4.26
4.15
13/
3136
18/
6180
14/
29/
5923* 5918
7016/ 9337/ 10913/ 13380/
11386 13422 13637 15333
-8.78%
3.91
2.74 6.21
11/
24/
4014 3866
3.09 6.06
3149/ 4064/
4988 6479
35.67%
16/
4095
4.56
15/
3293
10/
3238
1136/ 1874/
1774 3652
-58.75%
1.53
1/
655
1.57
1/
635
* BSI and VAP definition changed to NHSN as of 1/1/09 (previously NNIS)
** No data submitted
***No data available(little to no vents)
KEY - 2006-2009 comparison:
RED BOX=performance decline
GREEN BOX=improved or same
BSI - 86% (13/15 units) improved or stayed at zero, 2006 compared to 2009.
VAP - 54% (6/11 units) improved or stayed at zero, 2006 compared to 2009
VAP Bundle - 100% (11/11) improved and 73% (8/11) met goal of >90% compliance
0.00 0.00
85.45 85.45 100
N/A
96.8
96.8 97.87
0.00
0.00 0.00
0.00
100
96.67 96.3 96.1
99.7 98.49 99.6
86.45
116/
37266
Q2 Q3
2010 2010
0.00
0.00 21.28
25.19%
Q1
2010
KEY - 2006-2009 comparison updates:
AQUA BOX=zero infections for 12 consecutive months
YELLOW BOX=zero infection for 24 consecutive months
LT GREEN BOX=zero infection for 36 consecutive months
PINK BOX=zero infection for 48 consecutive months
PURPLE BOX=90% composite goal met
18/
2971
3.17
2/
631
63.13
64.04
62.73
51.31
81.33
5995/
7371
72.87
3601/
4942
91.06
93.97
96.3 93.75
2942/ 2599/ 2290/
3403 2818 2619
44.24%
7647/
8398
88.92
38.85%
5162/
5805%
58.33 71.73
98.4 95.52
1425/ 1505/ 1845/ 1898/
2443 2098
1873
1987
92.23 87.44
91.73 95.81 96.43
1631/ 1325/ 1162/
1778 1383 1205
88.59 94.43 96.58
1118/
1262
63.76%
830/
879
622/
644
99.47 98.02 98.54
376/
378
346/
353
337/
342
Q4
2010
Safety is our highest priority
Where are we now?
 169separate measures
 33 core
 Measures cover 5 main
dimensions of quality
 Effectiveness
 Patient Safety
 Timeliness
 Patient Centeredness
 Efficiency
2009 National Healthcare
Quality Report
Highlights
 Health care quality is suboptimal and
continues to improve at a slow pace
 Process measures are improving more rapidly
than outcome measures
 Health care quality measurement is evolving,
but much work remains
Trend in Quality Measures
 Median annual rate of
change for the 33 core
measures = 2%
 Treatment measures
improving more
rapidly than
preventive or chronic
measures
National Quality Report 2009:
AHRQ
Patient Safety is Lagging
 Safety rate of
improvement
is ½ rate of
quality
improvement
 But, better
than last year
2009 AHRQ Quality Report
Rhode Island Quality
Rhode Island
Dashboard on Health Care Quality Compared to All States
Overall Health Care Quality
http://statesnapshots.ahrq.gov/snaps08/dashboard.jsp?menuId=4
&state=RI&level=0 accessed on 1/14/2011
Rhode Island Quality
http://statesnapshots.ahrq.gov/snaps08/dashboard.jsp?menuId=4&state
=RI accessed 1/14/2011
“Organizations with a positive safety culture are
characterized by communications founded on
mutual trust, by shared perceptions of the
importance of safety, and by confidence in the
efficacy of preventive measures.”
—James Reason
• Open atmosphere for reporting and addressing
safety risks
• Careful monitoring and timely re-design of
internal patient care systems
• Commitment to the highest possible standards
of personal and collective accountability,
integrity, and professional behavior
The single greatest
impediment to error
prevention in the medical
industry is "that we
punish people for making
mistakes. Leape (2009)
68% of hospitals do not have
established environments that support
reporting
Farley, D.O., Haviland, A., Champagne, S., et al.
Adverse-event-reporting practices by US
hospitals: results of a national survey. Qual Saf
Health Care, 17|6|:416-23, December 2008
National Benchmarking Organizations
NACHRI
What didn’t I cover?
Measurement
Innovation and
Research
Patient Centered Care
Equitable Care
Efficiency, Effectiveness
What Not To Do
http://www.youtube.com/wa
tch?v=LhQGzeiYS_Q
QUESTIONS?
[email protected]...