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Patient Safety and Harm


Less than 30 day readmit. Post-op infection. Use of a 'rescue med' e.g. Narcan. Baseline Measures ... Category B: An error that did not reach the patient ... – PowerPoint PPT presentation

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Title: Patient Safety and Harm

Patient Safety and Harm
  • Michael ODell, MD, MSHA
  • Chief Quality Officer, NMHS
  • Residency Director, NMMC Tupelo

  • Unintended physical injury resulting from or
    contributed to by medical care that requires
    additional monitoring, treatment or
    hospitalization, or that results in death.

Disseminated Disease of Medical Progress?
  • Very few people would care to challenge the fact
    that our present day knowledge and capabilities
    have been productive of more good for mankind
    than harm. Can we, however, fully justify doing
    more harm to our patients simply because we can
    now do more good?
  • Seckler SG, Spritzer RC Disseminated Disease of
    Medical Progress. Arch Int Med 1966 117447-450

Harm Detected by Three Methods None Perfect
Baseline Measures
  • IHI Trigger Tools
  • Look for things like
  • Return to surgery
  • Less than 30 day readmit
  • Post-op infection
  • Use of a rescue med e.g. Narcan

  • No attempt made in harm tracking to ascertain
    whether an event was preventable
  • An adverse event is, by definition, harm

Severity Rating
  • Based on National Coordinating Council for
    Medication Error Reporting and Prevention (Only
    Categories E-I used)
  • Category A Circumstances or events that have the
    capacity to cause error
  • Category B An error that did not reach the
  • Category C An error that reached the patient but
    did not cause harm
  • Category D An error that reached the patient and
    required monitoring or intervention to confirm
    that it resulted in no harm to the patient
  • Category E Temporary harm to the patient and
    required intervention
  • Category F Temporary harm to the patient and
    required initial or prolonged
  • hospitalization
  • Category G Permanent patient harm
  • Category H Intervention required to sustain life
  • Category I Patient death

Never Events / Hospital Acquired Conditions 2007
Patient Safety
Agenda Item 2 and 3 Harm Measures and Composite
CMS No MCC/CC 2009 CMS No MCC/CC proposed
  • 14. Maternal Blood Transfusion
  • 15. 3rd or 4th Degree Perineal Laceration
  • 16. Normal Newborn Transfer to a Higher Level of
  • 17. Complication Associated with Anesthesia
  • 18. Postoperative physiologic and metabolic
    derangement CMS Poor gly control
  • 19. Postoperative Wound Dehiscence
  • 20. Postoperative Respiratory Failure
  • 21. Retention of a Foreign Object
  • 22. Air Embolism
  • 23. Blood Incompatibility
  • 24. Hospital Acquired Injuries
  • 25. Hospital Acquired Pressure Ulcers
  • Wrong Site Surgery
  • Surgical site infections ortho
  • Surgical site infections - bariatrics
  • DVT PE following certain ortho px
  • Poor Glycemic Control

1. Hospital Acquired Benzodiazepine Associated
Event 2. Hospital Acquired Narcotic Associated
Event 3. Hospital Acquired Poisoning 4.
Hospital Acquired Clostridium Difficile 5.
Hospital Acquired Staphylococcus Aureus
Septicemia 6. Hospital Acquired Central line
assoc Blood Stream Infections 7. Hospital
Acquired Catheter Associated Urinary Tract
Infections 8. Ventilator Associated Pneumonia 9.
SSI Mediastinitis after Coronary Artery Bypass
Graft (CABG) 10. Uterine Rupture 11. Birth Trauma
birth weight gt 2500 grams or 37 weeks 12. Birth
Trauma birth weight lt 2500 grams or 37 weeks 13.
Return to OR/LD
Is Medicine Getting Better?
Lake WoBeGon and its hospital
  • Where all the women are strong, the men are good
    looking, and the children are above average
  • Memorial Lady of the Lake Hospital-
  • where all the physicians are strong, the nurses
    are good looking, and the patient outcomes are
    above average

  • Improving care involves
  • The organization being organized to
    systematically improve care
  • The medical staff and licensed professionals
    their moral duty and accountability to improve
  • Medical staff and professionals must possess the
    competence and character to perform their
  • A major function of the organization is to
    reinforce and affirm the competencies and
    character of the medical staff and licensed
  • Organizational Resources, Personal Competency,
    Mutual Ongoing Demand for Excellence,
    Organizational Training and Support

Is All Harm Due To Error?
  • No!
  • Error may certainly cause harm
  • But not all error results in harm
  • Near misses
  • Error without effect

Can Harm Occur Without Error?
  • Yes!
  • Even well designed systems have unintended
  • Flawless execution of a process may still result
    in harm

Why Focus on Harm - I
  • Overall patient safety goal is to reduce patient
    injury or harm
  • Medical errors are numerous
  • Many have potential to be harmful
  • Numerous reports show that error is often not
    linked to injury

Why Focus on Harm - II
  • Focus on error tends to focus on individual
  • Focus on harm tends to focus on systems
  • Focus on systems more likely to improve care and
  • Focus on systems reduces fear of punishment and
    encourages cooperation with patient safety efforts

Commission v. Omission
  • Harm Measures focus on active care (Commission)
  • Excludes Omission (substandard care)

  • Harm Measures assess all adverse events
  • No attempt to determine preventability during
    chart reviews
  • Adverse Event Harm

IHI Global Trigger Tools
  • Institute for Healthcare Improvement
  • Use of manual chart review to study harm as a
    result of active medical care
  • Use trigger methodology to search for harm
  • Trigger event often associated with harm
  • If trigger present, chart reviewed further to
    determine if harm occurred

Triggers and Modules
  • Cares
  • Medication
  • Surgical
  • Intensive Care
  • Perinatal
  • Emergency Department

Example Cares Module Triggers
  • Transfusion of Blood or Use of Blood Products
  • Abrupt gt25 drop in Hemoglobin or Hematocrit
  • In-hospital stroke
  • Code or Arrest
  • New Onset Dialysis
  • Positive Blood Cultures
  • Full Measures http//

Conduct of Chart Review
  • Closed records gt 30 days post discharge and with
    completed discharge summaries and coding
  • Three person review team
  • Two record reviewers
  • Clinical background
  • Knowledge of contents of institutions medical
  • Knowledge of how care is provided in the hospital
  • Physician to authenticate consensus

Conduct of Chart Review II
  • Reviews performed on a sample of discharges
    (including deaths)
  • 20 records every two weeks
  • Record reviewed only for presence of triggers
  • If trigger found, then review of pertinent
    sections of the chart is conducted for presence
    of harm
  • Many triggers may be found but there will
    likely be far fewer episodes of harm
  • If an adverse event happens to be found without a
    trigger record it it is an adverse event

Conduct of Chart Review III
  • Was there an adverse event?
  • Defined as unintended harm from the viewpoint of
    the patient
  • Would you be happy if this happened to you? If
    no, then there was harm.
  • Was the event part of the natural progression of
    the disease or was it a complication of
    treatment. Harm should be the result of medical
    care interventions.
  • Was the event an intended consequence of care? A
    permanent scar following surgery is not harm.
  • Psychological harm is excluded

Conduct of Chart Review IV
  • Adverse events present on admission are still
    adverse events
  • Only significant events should be recorded
  • For our purposes at NMMC we tag as hospital or

Adverse Event to Trigger Ratio
  • National Coordinating Council for Medication
    Error Reporting and Prevention
  • Harm Measures adapt this classification
  • Only those classifications associated with harm
    are included
  • E Temporary harm to patient that requires
  • F Temporary harm to patient that requires
    initial or prolonged intervention
  • G Permanent patient harm
  • H Intervention required to sustain life
  • I Patient death

Presenting to the Board
  • Issues-
  • Lay persons
  • Focus
  • On impact on patients
  • On impact on institution

Patients Harmed v Not Harmed
Harm Type Pareto
Where does Harm Occur?
Length of Stay by Harm Type
  • Uniformly Increased

Event Associated Triggers (All)
Event Associated Triggers (Hosp)
If Harm, How Often?
Process for Reducing harm
  • Patient Safety Council
  • Use of Medical Staff Peer Review where
  • Discussions with outside agencies (e.g. Nursing