Mining for ADE Data

1. Mining for ADE Data Kim Werkmeister, RN, BA, CPHQ Cynosure Health National Improvement Advisor October 17, 2013

2. Why are ADE’s Such a Priority?

3. HAPU Falls ADE Readmissions VTE

4. The Goal 40% reduction Jan 2012 – Dec 2013

6. “We don’t have many ADEs”

9. So How We Find ADEs? • We have to look • We have to report • Someone has to listen • There can be no fear of reprisal

10. Where do we find ADEs? • The low yield: • Root Cause Analyses • Electronic data mining from electronic medical records • The high yield: • Voluntary reporting (if safe culture) • Triggers

11. What’s a Trigger? • “any event that sets a course of action in motion” Examples: • An abnormal lab result above or below a certain threshold • An admission lacking any VTE prophylaxis order • A transfer to a different level of care

12. Voluntary reporting • Does it work? • Why? • Why not?

13. Culture of Safety Do you have a non-punitive environment?

14. Keys to Voluntary Reporting • Make it SAFE • Make it EASY • Make it MEANINGFUL

15. Safe > Report > Aggregate > Analyze > Improve • Simple anonymous electronic error reporting system • Took nurses <1 min to enter • Organization wide id and password • Increased reports 100 fold over 6 months • Analyzed across broad steps in medication process • Found most errors related to administration of meds • Focus group of nurses • Complained of interruptions • Created ‘no interruption zone’ • Reduced errors by 30-40% over 3 months

16. How One CAH Reduced ADEs due to Hypoglycemia • D50 use on inpatients identified as ‘trigger’ • Vials of these drugs are wrapped with a small piece of paper before stocking in Pyxis. • Nurse completes paper upon administration of D50 • Dropspaperin designated box on unit by • Pharmtechsweepsdaily (weekly) • Data enteredintospreadsheet for tracking and trending (sensemaking)

17. Patient name  ___________________ Patient id #     ___________________ Date/time       ___________/________ Unit #  _____________ (    )  CHECK THIS BOX IF DRUG NOT USED FOR HYPOGLYCEMIA

18. What can we do with them when we find them? • Aggregate • Analyze • Look for system defects • Fix the system • It is about what and how not who

19. The Measures Hypoglycemia Anticoagulation Numerator: The # of inpatients with a high INR (organization defined) Denominator: The # of inpatients on warfarin Numerator: The # of inpatients who have severe hypoglycemia (<40) Denominator: The # if inpatients on insulin

20. So How Do We Prevent ADE’s?

21. Imaginethatit’sabusyday,andyoushrinkSan Franciscoairporttoonly1shortrunwayandonerampandonegate.Makeplanestakeoffandlandatthesametime,athalfthepresenttimeinterval,rocktherunwayfromsidetoside,andrequireeveryonewholeavesinthemorningreturnsthesameday. Makesuretheequipment issoclosetotheenvelopethatit’sfragile. Thenturnofftheradartoavoiddetection,imposestrictcontrolontheradios,fueltheaircraftinplacewiththeenginesrunning,putanenemyintheairandscatterlivebombsandrocketsaround.Nowwetthewholethingdownwithseawaterandoilandmanitwith20year-olds, halfofwhomhaveneverseenanaircraftcloseup. Oh,andbytheway,trynottokillanyone. Weick & Sutcliffe.Managingthe Unexpected2001

22. Designing Reliable Systems of Care Prevent Detect Mitigate

23. Human Factors Principles and Design • Avoid reliance on memory • Simplify • Standardize • Use constraints and forcing functions • Use protocols and checklists

24. Some examples

29. What is Safety? • Safety is a condition defined by the perception of the customer (patient). • Safety is not synonymous with the absence of risk or adverse events. Instead it is marked by the knowledge and comfort that all efforts are being made to prevent everything we know how to prevent and that we are striving to make things even better. • – Aviation, automobile, nuclear power • Error reduction, adherence to guidelines, best practices, etc are tactics, not strategies

30. High Reliability Organizations • Organizations that operate in hazardous environments but have low accident rates • Nuclear power, aircraft carriers, air traffic control, wild land firefighting, offshore drilling rigs • HROs are considered to operate with nearly failure-free performance records, not simply better than average ones • High risk and high effectiveness co-exist

31. Characteristics of HRO’s • Preoccupation with failure • Commitment to resilience • Sensitivity to operations • Deference to expertise • Reluctance to simplify

32. ADE Change Package • One page Overview • Driver Diagrams • Narrative with references • http://hret-hen.org/images/downloads/508changepacks/ade_changepackage_508.pdf