Maryland Association for Healthcare Quality Fall Conference Anne Arundel Medical Center Annapolis, MD October 29, 2009

1. Maryland’s Road to Patient Safety – Where Are We Now? Maryland Association for Healthcare Quality Fall Conference Anne Arundel Medical Center Annapolis, MD October 29, 2009 Vivian Miller, BA, LHRM, CPHQ, CPHRM, FASHRM Risk Management/Patient Safety Specialist Center for Performance Sciences

3. The Maryland Patient Safety Center became part of a unique approach to patient safety that was originally developed by the Maryland Health Care Commission (MHCC) in response to legislation passed by the Maryland General Assembly in 2001, which occurred almost immediately following Josie’s death. • Designated by the Maryland Legislature and the Maryland HealthCare Commission in 2004, our vision is to make Maryland’s healthcare the safest in the nation. • We want all Maryland hospitals tied for first place in the provision of safe, high quality care to our entire patient population.

4. The Maryland Patient Safety Center is a 501(c)3, non-profit organization, and as such, is governed by a voluntary Board of Directors comprised of Hospital Senior Executives, as well as representatives from Academia, MHA, the QIO, OHCQ, our patient population, and third party payors. The Executive Director is William Minogue, MD, a retired family practitioner and former hospital CEO The Director of Operations and Development is Inga Adams-Pizarro

5. Additionally, there is an MPSC employed Executive Assistant, and A programmer, along with myself, who are contracted staff through another MHA subsidiary to provide services on behalf of MPSC.

6. The Maryland Patient Safety Center has since been now re-designated as the state’s Patient Safety Organization from January 1, 2009 to December 31, 2014 • The Maryland Patient Safety Center has also been listed as a federal Patient Safety Organization for three years effective December 10, 2008 through December 9, 2011

7. The Maryland Patient Safety Center brings together health care providers to study the causes of unsafe practices and put practical improvements in place to improve the quality of care provided as well as to prevent medical errors. • This approach combines limited mandatory reporting of serious adverse events to the state health department with voluntary systems improvement activities coordinated by a statewide patient safety center.

8. To carry out its charge to improve quality of patient care and promote patient safety in Maryland, the Center focuses on the following four activities: • Collaboratives • Education • Research • Data Collection

9. Since July 2006, the Maryland Patient Safety Center has been collecting data after careful planning of how and what should be collected; and, what difference it can make to quality and safety of care

10. Today’s discussion is about the progress we have made, and how the data MPSC has collected over the last 4 years are being used by Maryland healthcare providers to their organization’s strategic patient safety initiatives. • It is also about analyzing key aspects of structures, processes, and outcomes of care that could have a direct impact on patient safety, as well as evaluating an organization’s progress toward a successful “culture of safety.”

11. Maryland Patient Safety Center Data • MPSC’s Adverse Event Reporting System (AERS) collects data related to • Adverse Events • Near Misses • RCA and FMEA Processes

13. Top 15 Incidents Reported by Volume, 2008

14. Summary of Incidents Reported by Volume, 2008 • Medication errors accounted for 21% of total incidents reported • 11% resulted in harm • Falls accounted for 16% • 23% resulted in harm • Laboratory incidents accounted for 11% • 8% resulted in harm • Provision of Care accounted for 11% of total incidents reported • 24% resulted in harm • Injury accounted for 8% of total incidents reported (i.e., Abrasion/Burn/Bumps; Aspiration; Blisters Broken or Missing Teeth; Bruise; Choking; Laceration (w or w/o Stitches); Needle Sticks; Self-inflicted Injury; Skin Tear; Struck by Object; Swelling/Edema)

15. Maryland Office of Healthcare Quality • Finding: Per the Office of Health Care Quality, for year 2008, Falls remain the most reported type of Level 1 Event that resulted in serious injury, illness and/or death. (More to come during the OHCQ Presentation)

16. Other patient characteristics are not reported to the OHCQ, but are associated with high risk for falling. • incontinence • age-related declines • chronic disease, acute illness • **medications (24.17% per MPSC data) Prevalence and Morbidity, and Causes, Chapter 21-Falls, Douglas P. Kiel, MD, MPH

17. There is a clear relationship between falling and: • **Polypharmacy, (patients being on more than 4 medications for acute care, on more than 9 for long term care) • Postural control, i.e., environment, changing positions, increase or decrease in normal activities • Other mediating factors, i.e., risk taking behaviors underlying mobility level such as disregarding fall prevention education by staff

18. This data were used to: • Assist in the establishment of a Falls Work Group • Develop and implement Roadmaps and Provide Tools designed to assist healthcare facilities across the continuum of care reduce the frequency and severity of falls • Data and other information was shared with the MEDSAFE Team for presentation at the 2008 Annual MEDSAFE Conference

19. Summary of 2008 Analysis Results, cont. • All levels of analysis indicate that MPSC participants’ greatest opportunities for improvement are within the following key elements • Patient Information • Staff Competency and Education • Quality Process and Risk Management

20. Summary of 2008 Analysis Results, cont. • Greatest opportunities for improvement within the following core characteristics: • Essential patient information is obtained, readily available in useful form, and considered when prescribing, dispensing, and administering medications • Essential drug information is readily available in useful form and considered when ordering, dispensing, and administering medications

21. Summary of 2008 Analysis Results, cont. • Practitioners receive sufficient orientation to medication use and undergo baseline and annual competency evaluations of knowledge and skills related to safe medication practices • Practitioners involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused

22. Summary of 2008 Analysis Results, cont. • A non-punitive, system-based approach to error reduction is in place and supported by management, senior administration and the Board of Trustees/Directors • Simple redundancies that support a system of independent double checks or an automated verification process are used for vulnerable parts of the medication system to detect and correct serious errors before they reach patients

23. Summary of 2008 Education Session • Don’t Fall on Your Meds! (September 25, 2008) • Medications’ Influence on the Risk of Falls – What the Data Suggests • National Perspectives on Fall Reduction Efforts • Medications that Put Hospitalized Patients at Risk for Falling • Patient Falls Case Review – Diuretics and Sleep Medications • Falls and Medication Safety – Systems and Processes • Discussions and Lessons Learned

24. So, what does the data show for 2009 to date?

26. Incidents Reported by Volume through September 2009 Total number of incidents reported 4784

27. Summary of Incidents Reported by Volume, through September 2009 • Laboratory errors accounted for 15% of total incidents reported, up 4% from 2008) • 1% resulted in harm • Medication errors accounted for 14% of total incidents reported (down by almost 5% from 2008) • 1% resulted in harm (down 22% from 2008) • Falls incidents accounted for 13% of total incidents reported (up 2% from 2008) • 34% resulted in harm • Provision of Care accounted for 11% of total incidents reported • 13% resulted in harm, (down 11% from 2008) • Injury accounted for 9% of total incidents reported, up 1% from 2008) (i.e., Abrasion/Burn/Bumps; Aspiration; Blisters Broken or Missing Teeth; Bruise; Choking; Laceration (w or w/o Stitches); Needle Sticks; Self-inflicted Injury; Skin Tear; Struck by Object; Swelling/Edema)

28. Future Considerations for MPSC based on Data • Drill down Laboratory Errors, determine possible contributing factors, i.e., improper collection, specimen mislabeled, patient identification, etc. • Drill down Provision of Care Errors, determine specific type of error, i.e., delay in treatment, delay in diagnosis, delay in response, etc., particularly in light of recent article published in JAMA. 2009;301(10):1060-1062, entitled “Diagnostic Errors—The Next Frontier for Patient Safety”, by David E. Newman-Toker, MD, PhD and Peter J. Pronovost, MD, PhD

29. According to the article, “....although the science of error measurement is underdeveloped, diagnostic errors are an important source of preventable harm.”

30. Next Steps for The Maryland Patient Safety Center (MPSC) • Continue to develop and deploy upgrades and improvements to the current adverse event reporting system so that data collected accurately reflects what types of events are actually taking place in Maryland hospitals • Provide a routine, comparative data review and analysis for each participating institution, including near miss data • Provide an annual report on identified trends within each participating institution, also including comparisons to other regional and national data • Provide an annual assessment of the status of patient safety efforts in participating institutions to show how MPSC and the Adverse Event Reporting System has contributed toward making Maryland’s Healthcare “the Safest in the Nation”.

31. Questions?

32. For more information, contact: vmiller@mhaonline.org kwicker@mhaonline.org dbonistalli@mhaonline.org (410) 379-6200