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Pursuing Perfection: Preventing Harm to our Patients

Pursuing Perfection: Preventing Harm to our Patients. Mary Reich Cooper, M.D., J.D. Senior Vice President and Chief Quality Officer, Lifespan Asst. Professor, Medicine, Alpert Medical School of Brown University February 5, 2011. My first deposition: I was not yet a J.D.

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Pursuing Perfection: Preventing Harm to our Patients

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  1. Pursuing Perfection:Preventing Harm to our Patients Mary Reich Cooper, M.D., J.D. Senior Vice President and Chief Quality Officer, Lifespan Asst. Professor, Medicine, Alpert Medical School of Brown University February 5, 2011

  2. My first deposition: I was not yet a J.D.

  3. Agenda: Institute of Medicine Approach to Quality Effective Effective Patient-Centered Timely Equitable Efficient SAFE IOM 2001 Crossing the Quality Chasm

  4. Safety Surveys Safety Culture Safety Rounds Crew Resource Management Team Training Just Culture Medical Errors/Adverse Events Near Misses & Good Catches Unsafe Conditions RCAs FMEAs PSOs Safe Care: The Past Decade

  5. Event # 1 You are the doctor in charge.

  6. Monday 11 am

  7. Event Occurs Responsibility, Accountability, Culpability?

  8. RIH Events: 2004 -2011 • 2007 • January: wrong side neurosurgical drainage of subdural hematoma bedside • July: wrong-side drainage of subdural hematoma operating room main • November: wrong side neurosurgical drainage of subdural hematoma bedside • 2009 • May: wrong-side palate children’s operating room • October: wrong site finger ambulatory operating room

  9. Rhode Island HospitalSurgery Cases

  10. Surgery Errors/100,000 Patient Days

  11. The National Experience

  12. Source: Seiden S, Barach P. Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events. http://archsurg.ama-assn.org/cgi/content/full/141/9/931. Acessed October 27, 2009.

  13. RHODE ISLAND HOSPITAL 0 0 0 0 0 Source: Commonwealth of Massachusetts Department of Public Health 2008 Report: Serious Reportable Events in Massachusetts Acute Care Hospitals http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/sre_acute_care_hospitals.pdf

  14. RHODE ISLAND HOSPITAL 0 0 2 2 Source: Commonwealth of Massachusetts Department of Public Health 2009 Report: Serious Reportable Events in Massachusetts Acute Care Hospitals http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/sre_report_2009.pdf

  15. Source: Connecticut Department of Public Health Legislative Report to the General Assembly: Adverse Event Reporting October 2008 http://www.ct.gov/dph/lib/dph/government_relations/2008_reports/oct2008_adverseeventreport_finaldraft.pdf

  16. Wrong Site Surgery – Are They Preventable? Wrong-side/wrong-site , and wrong patient adverse events (WSPE) are more common than previously reported. Based on theseveral available databases these adverse events have beenoccurring steadily for years without significant attention orevidence of reduction in prevalence. The data support widespreadunderreporting of these adverse events. At a minimum, assuming100% of cases are reported, our extrapolation of data from Floridapredict that there would be 1321 cases in the United Statesannually. However, multiple studieshave demonstratedthat the compliance of physicians in reporting has ranged from5% to 50% of events thus predicting a WSPE incidence of2600 events in the United States annually. Source: Seiden S, Barach P. Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events. http://archsurg.ama-assn.org/cgi/content/full/141/9/931. Acessed October 27, 2009. Arch Surg 2006;141;931-9

  17. Event # 2 You are the doctor in training.

  18. Wednesday 2 am

  19. Event Occurs Responsibility, Accountability, Culpability?

  20. Your mistake, Paper’s headlines

  21. Minnesota Experience Source: Minnesota Department of Health: Adverse Health Care Events Reporting System: What have we learned? 5-year REVIEW (2003-2008) http://www.health.state.mn.us/patientsafety/publications/2010ahe.pdf

  22. Mandated Reporting: http://www.jointcommission.org/sentinel-event-statistics/ accessed 1/14/2011

  23. Medicare Says It Won’t Cover Hospital Errors • Sign In to E-Mail or Save This By ROBERT PEAR Published: August 19, 2007 WASHINGTON, Aug. 18 — In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars…..

  24. HAC: Preventable Complications 1. Object left in surgery 2. Air embolism 3. Blood incompatibility 4. Catheter Associated Urinary Tract Infection 5. Pressure Ulcers 6. Catheter Associated Blood Stream Infection 7. Surgical Site Infection – Mediastinitis; Orthopedic; Bariatric • Injuries • Glycemic Control (Blood Sugar) • DVT (Clots)

  25. Event # 3 You are the medical student.

  26. Saturday 2 pm

  27. You see this….

  28. Event Occurs Responsibility, Accountability, Culpability?

  29. Why Is This Picture Important? Stage I Pressure Ulcer (Bed Sore)

  30. Why are Pressure Ulcers Important? • The annual cost for treating pressure ulcers in the US ranges between 2.2 and 3.6 Billion dollars • Rhode Island begins public reporting on hospital-acquired pressure ulcer assessments in 2009 • CMS stopped paying hospitals for Stage 3 and 4 hospital-acquired pressure ulcers in October 2008 • Over the past 10 years, we have paid out 1.5 million dollars in claims brought for patients who developed pressure ulcers • NDNQI requires pressure ulcer reporting • Pressure ulcers are no longer “nursing” indicators

  31. Event # 4 You are a doctor on the team.

  32. Wednesday 7 pm

  33. Event Occurs Responsibility, Accountability, Culpability?

  34. On a given day at Lifespan Hospitals… • 85 medication errors (actual and prevented) will be reported • 39 actual medication errors will be detected and reported • 46 medication errors will be prevented • MAK will prevent… • 6 “Wrong patient” medication related errors (bring up a patient record and scan the patient’s bracelet, not a match) • 6 “Wrong drug,” Wrong dose,” “Wrong route” errors (have correct patient record that matches the patient’s bracelet, but scan of medication reveals drug error) • 30 prescribing errors will be prevented • 5 excessive doses of medication will not be given • 1 drug allergy will be avoided

  35. Innovation Electronic Medical Records

  36. Innovation Smart Pumps

  37. Innovation Patient Identification

  38. Event # 5 You are a doctor on the team.

  39. Tuesday 10 am

  40. Event Occurs Responsibility, Accountability, Culpability?

  41. National Healthcare Safety Network (NHSN)

  42. Rhode Island ICU Collaborative

  43. Safety is our highest priority

  44. Where are we now? • 169separate measures • 33 core • Measures cover 5 main dimensions of quality • Effectiveness • Patient Safety • Timeliness • Patient Centeredness • Efficiency 2009 National Healthcare Quality Report

  45. Highlights • Health care quality is suboptimal and continues to improve at a slow pace • Process measures are improving more rapidly than outcome measures • Health care quality measurement is evolving, but much work remains

  46. Trend in Quality Measures • Median annual rate of change for the 33 core measures = 2% • Treatment measures improving more rapidly than preventive or chronic measures National Quality Report 2009: AHRQ

  47. Patient Safety is Lagging • Safety rate of improvement is ½ rate of quality improvement • But, better than last year 2009 AHRQ Quality Report

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