Adverse Event Reporting The New York Experience 2nd Annual Betsy Lehman Center Patient Safety Symposium Reporting, Disclosure and Accountability

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Adverse Event ReportingThe New York
Experience2nd Annual Betsy Lehman Center
Patient Safety Symposium Reporting, Disclosure
and Accountability

• Ellen Flink, MBA
• NYS Department of Health
• December 5, 2005

NEW YORK STATE DEPARTMENT OF HEALTH
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How NY got started

• Response to the medical malpractice crisis of the
  80s
• First incident reporting system effective October
  1985
• Statutorily based in Laws of 1986
• NYPORTS development part of the regulatory reform
  effort of 1995

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Three iterations

• Beginning in 1985 with HIRS-a paper driven system
• Continuing with PETS in 1993-based on algorithm
  of treatment and harm
• Re-worked and overhauled into NYPORTS-implemented
  in 1998
• Ongoing refinements and updates

NEW YORK STATE DEPARTMENT OF HEALTH
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Are we where we hoped to be?Where we are now..

• Reporting rates have stabilized
• Robust secure web based system
• Shift from individual to systems approach
• Focus on quality
• Embrace culture of safety
• Data analysis and dissemination of lessons
  learned for improvement

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NYPORTS Cases by Year 2000-2004
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Reporting of Individual NYPORTS Codes 2002 - 2004
401- PE 402- DVT 604- AMI 751- Falls 801-
Procedure related
injury 803-Hemorrhage or hematoma 808- Post-op
wound infection
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Shifting the perspective from bad apples to bad
systems is not entirely intuitive. Armies,
airlines, power plants learned this lesson long
ago and made the required changes.
- Wachter and Shojania
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Institute of Medicine To Err is Human Building
a Safer Health System
November 1999

• Preventable medical errors
• 44,000 to 98,000 Americans die each year
• Eighth leading cause of death in the United
  States
• Cost as much as 29 billion annually
• IOM conclusion the majority of these problems
  are systemic, not the fault of individual
  providers

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Culture of Safety

• We must do more to create a collaborative culture
  in health care one in which providers at all
  levels feel free to report and learn from their
  mistakes, act in concert, and voice their
  concerns while there is still time to do
  something about them. This culture will require
  substantial new training, inservice coaching, and
  patience..

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Data Analysis and Dissemination

• NYPORTS Statewide Council
• Regional Forums
• Professional Organization Meetings
• NYPORTS News and Alert
• NYPORTS Bulletin Board
• NYPORTS Educational Videoconferences
• Annual reports
• Patient Safety Conference
• New York Patient Safety Award Program

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Current System Refinements

• Significant system enhancements effective June
  2005
• Retirement of 15 occurrence codes
• Converted to Microsoft.Net technology
• Improved canned and custom reports
  functionality
• Implemented RCA Evaluation Tool
• New Process Measures Project
• Developing new clinical specialty panels
• Changes were made based on user survey and wish
  list

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Lessons Learned

• Information must be meaningful and useful to end
  users
• Obtain buy in by involving stakeholders in the
  development process
• Confidentiality protections are important
• Web based system allows facilities to access data
  and produce reports
• Ongoing training and educational support
• System design must allow for meaningful
  changes/improvements
• Clear definitions of reporting criteria reduces
  variability
• Analysis and dissemination of data is a key to
  improvement

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Other Challenges

• Completeness of reporting
• Resources to support system
• Quality and accuracy of RCAs
• Clinical analyses of data
• Ongoing Education and Training
• Quality improvement monitoring and evaluation
• Evolution of NYPORTS - CQI

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Are we safer?

• Opportunities for improvement
• Facilities can measure effectiveness of system
  changes over time
• Sharing data on multiple levels can lead to
  system wide change
• Since there is no way to assure complete
  reporting, we cant measure whether changes in
  reporting rates are due to improved care.

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Patient Safety Improvement

• Systems thinking
• Human Factors Engineering
• Keep the safety of patients at the center of all
  safety decisions
• Culture change

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Patient Safety

• Partially charted territory
• Human Factors Engineering FMEA beyond
• Counting reports IS NOT the objective,
  identifying vulnerabilities IS
• Analysis, action and feedback are key
• Prevention NOT Punishment
• Cultural change takes time
• Safety is the foundation upon which Quality is
  built
• - VA National Center for Patient Safety

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Bottom Line

• We dont know what we dont know!

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Impact of 2005 Patient Safety Legislation

• Patient Safety Center in DOH
• State Legislation in 2000 requires the
  establishment of a voluntary near miss
  reporting system
• DOHs Patient Safety Center will consider
  becoming a PSO
• Too early to make a determination

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The only real mistake is the one from which we
learn nothing.
-John Powell