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Systems for Safety

Systems for Safety. June 2006. Much has Been Done … Trend in Age-Adjusted 30-Day In-Hospital Death Rate. Excludes NL, QC, BC. ¼. But Challenges Remain. of Canadian adults report that they, or a family member, experienced a preventable “adverse event”. How often do adverse events happen?.

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Systems for Safety

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  1. Systems for Safety June 2006

  2. Much has Been Done …Trend in Age-Adjusted 30-Day In-Hospital Death Rate Excludes NL, QC, BC

  3. ¼ But Challenges Remain of Canadian adults report that they, or a family member, experienced a preventable “adverse event”

  4. How often do adverse events happen? 1 / 9 1 / 11 1 / 81 Adults with health problems given wrong medication/dose Hospital-acquired infection (kids) Birth trauma

  5. How often do adverse events happen? 1 / 1,124 1 / 6,667 1 / 10,000,000 In-hospital hip fractures for seniors Foreign object left in Infected transfusion blood: HIV

  6. Information for Improvement…

  7. Data Systems for Safety: Addressing Many Challenges • How do we identify for follow-up: • Patients at risk of adverse events • Patients who may have experienced an adverse event • How do we know the extent of the problem and how it is changing? • How do we know which changes to try? • How do we know that change is an improvement? • How can we demonstrate accountability? • How do we learn and spread lessons from adverse events or near misses? • Etc.

  8. Tracking Progress: Vital Signs - Overall mortality trends BigDot • Trends in care processes • Intervention-level outcomes Projectby Project • Tracking team’s care processes Team by Team

  9. Medication Incidents: Example #1 • Information on number, types, sources, causes and outcomes… • Is needed to • Identify areas requiring change • Identify potential preventative strategies • Assist in implementing strategies that have been shown to reduce the risk of incidents • Evaluate implementation outcomes

  10. Chart reviews Different approaches for different needs … EHR & Decision-support Patient Safety Surveys Indicators Reporting Systems

  11. Type of Data Source Required Current Data Sources Modified Data Sources Expanded Data Sources No Current Data Source Total Client/patient or population surveys 9 5 17 - 31 Provider survey data 6 4 5 15 Organization survey data - - 21 2 23 Clinical administrative data 1 3 12 17 33 Other administrative data 2 - - 1 3 TOTAL 18 12 55 20 105 Primary Health Care Indicators: Example #2

  12. Information for Improvement What is the Potential?

  13. At the Practice LevelCHF Collaborative in BC Source: http://www.heartbc.ca/pro/collaboratives/chf/docs/chf-finalposter.pdf

  14. The Pharmanet Story • Out of 35 million prescriptions in 2003 • 7.9 million potential interactions flagged • 12% “most significant” • Generally require action to reduce risk of serious adverse event • Most common reasons for not dispensing as written in 2003 • Consulted provider, changed dose/instruction • Sub-therapeutic dose • Prior adverse reaction

  15. Adverse Event Reporting

  16. Informing Management Decisions • Within a year, 92% of Ontario hospitals had taken action based on data reported in the Hospital Reports • Common areas for action included improving communication and coordination of care

  17. Regional Differences 2002–2003 to 2004–2005, excluding QC & NL

  18. The Road Ahead …

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