“A Tale of Two (Reporting) Systems”

1. “A Tale of Two (Reporting) Systems” Betsy Lehman Center's 2nd Annual Patient Safety Symposium 5-Dec-2005 H S Kaplan Columbia University New York Presbyterian Hospital

2. What got us started?Prior experience with a domain specific web-based reporting system • MERS-TM: transfusion event reporting system developed under NHLBI RO1 grant. • Could MERS-TM provide a useful platform for a General Medical System: MERS-TH? • MERS-TH - an AHRQ U18 Demonstration Grant

3. Where did we start? : Paper-based,multiple forms,hospital event- reporting system • Accessibility limited • Information often dead- ended • Mainly reactive to significant events • Physician role limited • Environment not supportive • Limited feedback

4. Tension Between Accessibility and Security Good News re automation • Reducing the number of paper report forms • Improved access and availability • decrease dead ends • More timely Bad News • (Still need someone to look at it) • Increased need to control access • HIPPA And medical/legal

5. Role-Based Access and Notification • Organization Tree • roles • privileges • Overarching Access Rule Set (derived from organization tree) • Location • Service line • Types: falls, meds, transfusion, equip, etc.

6. Where we are now?: Web-based hospital-wide event reporting • Standardized reporting form for the entire hospital network • Automatic routing of reports to all relevant hospital personnel. • Accessible to reporters through any web browser • Proactive: emphasis on near-miss as well as significant events • Central database: process improvement, on-line query tools

7. Push: Event report forms are distributed to all relevant parties in real-time

8. Pull: Conjunctive Query by Field-Empowering the End User End user able to build queries without understanding database design or table relationships. 3. 2.

9. Still a work in progress… • Physician involvement still limited • Improving, especially with champions • Environment in transition • “Just” culture being implemented • Near-miss • Feedback still limited • Includes Unit Manager • Query by Form • Preparing standard reports

10. Who Are Reporters? 2% 87% 5% 3%

11. Physicians as Reporters

12. Lessons learned • Adoption not just compliance is critical • Innovators and champions • Time spent • Integration into existing quality assurance processes, • M&M • Nursing reports • Near misses – volume increase • Hazard matrix • Consequences / Significance • Tension between access and confidentiality • Controlling information access

13. Are We Safer Today? • Early warning system – near misses • Identifies types of events and aids in estimates of magnitude of threats to patient safety • Identifies latent system (of care) problems. • Guides formulation of corrective actions

14. Wrong Pump Infusion SettingsOrdered in ml/hr but given in ml/min No harm events

15. We See What We Expect to See • Events only in rental pumps • Some caregivers didn’t “see” ml/min setting (non-rental pumps – ml/hr was default setting) • Pattern of events seen by QA upon querying MERS-TH dataset • 30-50 rental pumps (30% of all pumps) with 225 patients treated in these units per month • Biomed locked in default setting ml/hr, created checklist for monitoring rental equipment

16. The Challenge of Legislation: Will a possible increase in hospital-wide reporting systems, cause us to lose the benefits of domain specific systems? "To conceive of knowledge as a collection of information seems to rob the concept of all of its life... Knowledge resides in the user and not in the collection.” C.West Churchmanin The Design of Inquiring Systems

17. “Ability is the art of getting the credit for all the home runs somebody else hits” -Casey Stengel, baseball manager International Center for Healthcare Outcomes and Innovation (InCHOIR) CUMC: A. Gelijns, A. Moskowitz, R. Levitan, N.Egorova Department of Pathology CUMC: Barbara Rabin Fastman

18. Thank you for your attention