Healthcare- Data Reporting, Medical Errors, and Consumer Awareness Sharon Bartelt, RN,MSN,MBA,CPHQ, ASQ- SSBB

1. Healthcare- Data Reporting, Medical Errors, and Consumer Awareness Sharon Bartelt, RN,MSN,MBA,CPHQ, ASQ- SSBB

2. Data Reporting in Healthcare • Quality Data Reporting is required for accreditation • Public reporting is voluntary • SC DHEC requires Infection Prevention data published • Hospital Infections Disclosure Act (HIDA) • Hospital acquired infections • Surgical Site Infections (SSI) • Central line Bloodstream Infections (CLABSI) • MRSA • Websites compare hospital outcomes data • oregon.gov/OHPPR/HQ- compare mortality rates • CMS.gov • Leapfroggroup.org • Data.medicare.gov

3. Data Reporting in Healthcare • Agency for Healthcare Research & Quality (AHRQ) • SCHA Public reporting site • MySChospital.org • The Joint Commission (TJC) • Hospitals submit via approved vendor • JC.org • Centers for Medicare and Medicaid (CMS) • MedPAR data ( Medicare database)

4. Quality Indicators…… • Abdominal Aortic Aneurysm (AAA) repair mortality rate • Acute myocardial Infarction (AMI) mortality rate • CABG mortality rate • Carotid Endarterectomy (CEA) mortality rate • Acute Stroke mortality rate • AMI mortality rate- without transfers • Congestive heart failure (CHF) mortality rate

5. Quality Indicators…… • Craniotomy mortality rate • Esophageal resection mortality rate • GI hemorrhage mortality rate • Hip fracture mortality rate • Hip replacement mortality rate • Pancreatic resection mortality rate • Pneumonia mortality rate • Percutaneous Coronary Angiogram (PTCA) mortality rate

6. Volume- Surgical procedures • Abdominal Aortic Aneurysm repair (AAA) volume • Coronary Endarterectomy (CEA) volume • Coronary Artery bypass graft (CABG) volume • Esophageal resection volume • Pancreatic resection volume • Percutaneous transluminal coronary angioplasty volume

7. Reportable Events (DHEC) • Elopement from a behavioral health unit • Fall resulting in Fracture/serious injury • Death of a patient within 24 hours of discontinuing a restraint (CMS) • Fire- contact Fire Marshall

8. Investigation Outcomes • Surveyors arrive unannounced • State purpose • Request documentation, records • Request to interview staff • Complaint is unsubstantiated – no further action • Complaint is substantiated- response due in 15 calendar days • 4 hours to 5 days

9. Medical Errors ….. • Sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called "sentinel" because they signal the need for immediate investigation and response.

10. Sentinel Event • Self report– • Investigation • Healthcare facility files written report with JC • JC discovers via media (AP) • On site review • SC • 173 reviewed between Jan 1995 to Dec 2008 • Illinois • 319 reviewed between Jan 1995 to Dec 2008

11. Sentinel Events by Type • Anesthesia-related • Assault/Rape/Homicide  • Delay In Treatment  • Elopement  • Fires • Infection-related • Maternal Deaths • Medical Equipment • Medication Error • Op/Post-op • Patient Abductions • Patient Falls • Perinatal Death/Injury • Potassium Chloride • Restraint Deaths • Suicide • Transfusion • Unintended Retention of Foreign Objects • Ventilator • Wrong-site Surgery

12. Sentinel Events • Total number Reviewed by Joint Commission…… 6923 since January 1995 • Wrong Site Surgery– 921 13.3% • Suicide 816 11.8% • Op/post-op complication 749 10.8% • Delay in treatment 592 8.6% • Medication error--- 554 8.0% • Patient fall 450 6.5% • Unintended retention of foreign body 383 5.5% • Assault/rape/homicide 263 3.8% • Perinatal death/loss of function 217 3.1% • Patient death/injury in restraints 202 2.9% • Transfusion error 148 2.1% • Infection related event- 148. 2.1% • Medical Equipment-related 138 2.0% • Fire 105 1.5% • Anesthesia Related 102 1.5% • Patient elopment 102 1.5%

13. Sentinel Events • Maternal death 95 1.4% • Ventilator death/injury 64 0.9% • Abduction 32 0.5% • Utility systems-related event 25 0.4% • Infant discharge to wrong family 9 0.1%

14. Sentinel Events by Location • General hospitals—3776 • Psychiatric hospitals 610 • Psychiatric Units 290 • Non acute behavioral health 257 • Emergency department 256 • Long term care facility 157 • Ambulatory care Setting 151 • Home Care 109 • Clinical laboratory 9 • Healthcare Network 2

15. Sentinel Event Follow UP • Failure Mode Effects Analysis • Apologize • Full explanation to SO/ family • Reporting to Joint Commission

16. SPEAK UP CAMPAIGN Consumer Awareness Is Key Speak up if you have questions or concerns. If you still don’t understand, ask again. It’s your body and you have a right to know.Pay attention to the care you get. Always make sure you’re getting the right treatments and medicines by the right health care professionals. Don’t assume anything. Ie Is this my diabetic medication? Educate yourself about your illness. Learn about the medical tests you get, and your treatment plan. .

17. SPEAK UP CAMPAIGN Consumer Awareness Is Key Ask a trusted family member or friend to be your advocate (advisor or supporter). Know what medicines you take and why you take them. Medicine errors are the most common health care mistakes Use a hospital, clinic, surgery center, or other type of health care organization that has been carefully checked out. For example, The Joint Commission and other accrediting bodies survey hospitals to see if they are meeting the JC standards and CMS CoP Participate in all decisions about your treatment. You are the center of the health care team.

18. Informed Consumer… • Request the complication rate and mortality rate of procedure by the physician • Request the number of procedures the physician has performed • Question the RN re: medications, procedures • If med appears to be difference color, shape, size • If no discussion of procedure

19. Publications Available • Help Prevent Errors in Your Care • Help Avoid Mistakes in Your Surgery • Information for Living Organ Donors • Five Things You Can Do to Prevent Infection • Help Avoid Mistakes With Your Medicines  • What You Should Know About Research Studies   • Planning Your Follow-up Care  • Help Prevent Medical Test Mistakes • Know Your Rights • Understanding Your Doctors and Other Caregivers • What You Should Know About Pain Management • Prevent Errors in Your Child’s Care • Stay Well and Keep Others Well (a coloring book for children) • Tips for Your Doctor’s Visit

20. NEVER EVENTS • Surgery performed on the wrong body part • Surgery performed on the wrong patient • Wrong surgical procedure performed on a patient • Leaving a foreign object in a patient after surgery or other procedure • Death of a healthy person during surgery or right after surgery • Artificial insemination with the wrong sperm or donor egg • Surgical site infection/swelling between the lungs (mediastinitis) • Surgical Site infection/ swelling between the lungs ( mediastinitis) after coronary artery bypass graft (CABG) surgery

21. NEVER EVENTS ……. • Surgical site infection following bariatric surgery for obesity • Surgical site infection following bariatric surgery for obesity • Surgical site infection after certain orthopedic procedures • Blood clots in legs or lungs (Deep Vein Thrombosis and • Blood clots in legs/ lungs (DVT/PE) pulmonary embolism) after certain orthopedic procedures

22. CMS NEVER EVENTS- 2010 • Surgical site infections following certain elective procedures, such as orthopedic surgeries and bariatric surgery for obesity; • Manifestations of poor glycemic control; • Deep vein thrombosis or pulmonary embolism following certain orthopedic surgeries, such as total knee replacement and hip replacement.

23. NEVER EVENTS • Death/serious disability from contaminated drugs, devices, or biologics • Death/serious disability from improper use of a device • Death/serious disability from air in a vein (intravascular air embolism) • Death/serious disability from a drug error • Death/serious disability from getting incompatible blood product(s) • Maternal death/serious disability associated with labor/delivery in low-risk pregnancy • Death/serious disability from poor blood sugar control (hypoglycemia • Death/serious disability from failure to identify and • treat jaundice in newborns • Very serious (stage 3 or 4) bed sores acquired after admission

24. NEVER EVENTS…… • Death/serious disability from spinal adjustments (spinal manipulative therapy) • Urinary tract infection from a urinary catheter • Infection from a vascular catheter • Infant discharged to the wrong person • Death/serious disability after a patient disappears for more than 4 hours • Suicide or attempted suicide that leads to serious disability • Death/serious disability resulting from an electric shock in a health care facility • Any time when a patient gets the wrong gas or contaminated gas • Death/serious disability resulting from a burn in a health care facility • Death/serious disability resulting from a fall in a health care facility

25. NEVER EVENTS • Death/serious disability from the use or lack of restraints or bedrails • Any time care is ordered/provided by someone impersonating a doctor, nurse or other provider • Abduction of a patient • Sexual assault on a patient • Death/significant injury of patient or staff member from physical assault

26. Always remember……. • Ask questions • Get an advocate • Check the accreditation/ rating/ of a healthcare facility • Heathgrades.com • Participate in ALL healthcare decisions • Educate yourself • Request physician complication rate/ mortality rate • Request physician data: number of cases/ procedures performed

27. Questions