Never Events Board Presentation Lisa Beckman, Connie Egerer, Kerry Heinecke

1. Never Events Board PresentationLisa Beckman, Connie Egerer, Kerry Heinecke Med Inf 404, Spring 2010

2. Hospital Background • Mid-State University Medical Center is a large mid-western university hospital complex • Adult patient hospital is an 11-story, 550-bed, 1.8 Million sq. ft. hospital, opened in 1986 • Children’s hospital is a 9-story, 350-bed, 700,000 sq. ft. hospital opened in 2008 • Each house diagnostic equipment, clinical laboratories, operating rooms and inpatient and intensive care units • 70 percent of patients are admitted from other communities or regional hospitals

3. Never Events Background • IOM Reports raised awareness of medical errors • CMS lists 17 never events which are non-reimbursable hospital acquired conditions • NQF Serious Reportable Event (SRE) list covers 28 types of events grouped in 6 categories • Purpose of the SRE’s is to facilitate public accountability for occurrence of medical errors. • No federal law mandating reporting; many states have enacted laws requiring reporting of SREs

4. Serious Reportable Events Quality Initiative Progress and Recommendations

5. Presenters • Lisa Beckman, Chief Executive Officer • Connie Egerer, Chief Quality and Safety Officer • Kerry Heinecke, Director of Risk Management Board Meeting

6. Agenda • Key Objectives • SRE Dashboard • 2008 / 2009 Results for NQF Serious Reportable Events (SRE’s) • Comparison to Similar Institutions • Pareto Analysis • Example SRE • Recommendations • Conclusion

7. Key Objectives • Safe • Patient Centered • Effective • Efficient • Timely • Equitable

8. 2010 Dashboard Key SRE’s

9. Serious Reportable Events

10. Breakdown of Category

11. Serious Reportable Events

12. Pareto Analysis

13. Device Event Example FILM DR

14. Device Event Example • November 2009 • Relatively new x-ray technology • Experienced x-ray tech • Dispatched to PICU for portable x-ray on 2 week old infant POD 1 from open heart surgery to repair complex Congenital Heart Defect • Intubated • Open sternum • Multiple chest tubes, • IV’s, intracardiac lines • Dopamine/Epi to maintain BP

15. SRE Event detail • Physician requests to view

16. Consequences Extubated – required reintubation Skeletal series & cranial Ultrasound to Rule Out injury Family distress Caregiver distress No obvious sustained injury Hospital absorbed extra cost Hospital paid for family’s meals and lodging in Hotel $100,000 detector plate shattered

17. Potential Consequences • Severe injury or disability • Prolonged hospitalization • Death • Even more severe family and caregiver distress • Publicity/damage to reputation • Lawsuit

18. Root cause analysis • This was still a new process- detector/(plate) now tethered to machine with cable • Tech was distracted and reverted back to old habit of pulling machine away quickly • Near misses not taken seriously enough • RN and RT not “engaged” in x-ray taking process – distracted

19. IMPROVEMENT PRINCIPLES • The safest thing to do is the easiest thing to do • Reduce reliance on memory • Use fail-safe systems and forcing functions • Standardize and simplify processes • Design systems to be resistant to psychological and environmental precursors to error – reduce stress in the environment • Enhance access to complete & timely information

20. How did we fix this? • Met with product rep to discuss safety issue • Sensor added to the storage slot for the detector • Activates switch when in detector in place • Switch must be active to move backwards (i.e. plate must be in place, otherwise machine in veryslow mode) • 3 “Must do’s” with EVERY portable x-ray • MUST have second assist with plate/detector removal (RN, RT, MD, Tech) • MUST state out loud “Are we ready to remove the detector?” • MUST have OK from second assist: “Lines and tubes secure. It’s OK to remove the detector.”

21. How did we fix this? • Retraining of all techs • Must pass competency in Simulation center • Emphasized 3 “Must do’s” • 2 techs together for portables for the next 3 weeks • Chief safety officer sent memo to all clinicians and managers: • “Do Not Distract X- Ray Technician” • 3 “Must do’s” with EVERY portable x-ray • Near miss log

22. How do we prevent SRE’s? We can benefit from lessons learned from the adoption of an EMR by recognizing the following: • The hospital is becoming a more and more complex environment • New errors result from the use of complex technology in a very complex work environment • Anticipate the unintended and actively look for problems • End users must be encouraged to report problems found, including near misses SRE’s

23. Evaluation • Who are the customers • External • Internal • What is important to them • How do we measure what is important • How are we doing

24. Recommendations • Continue to promote safety culture • Safety champions throughout the hospital • Develop internal web page for equipment/technology safety issues • Staff can easily submit information • Near misses • New ideas • Safety issues in general • Reward staff for good ideas

25. Recommendations • Form committee to evaluate new product or device use • Quality and Safety officer • Unit/department Managers • Key unit educators • Vendor rep • Must include users from all relevant departments

26. Recommendations • Committee Agenda: • HLPM of current process • HLPM of new process • Highlight significant differences • Encourage end users to “Anticipate the unintended and actively look for problems” • Consider use of a Simulation Center for training • Establish check-off requirements • Consider use of a buddy system for high-risk procedures for defined training period

27. Resources Required • Staff release time for committee work • Membership of committee changes with each new product/device introduced • Requires back-up coverage • Staff time to complete the analysis and to develop new procedures and training • Staff time for training • Developer time for web page • Vendor contracts to include participation

28. Resources Required • Clinical Simulation Center – use existing equipment for training • SimMan • PediaSim • Neonatal simulator • Consultation with Simulation Center Training Staff

29. Conclusion • Safety focus program on SRE’s has been successful in reducing numbers of surgical events • Current priority is reduction of Product or Device SRE’s • Questions

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