Serious Reportable Events

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Serious Reportable Events

• a summary of recent activities

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DPH mandates reporting of NQF events

• Background Long standing requirement for
  hospital reporting of serious events did not use
  terminology consistent with NQF list of 28 events
• Action step In December, 2007, DPH notifies
  hospitals of new requirements of use of NQF
  categories in reporting of serious reportable
  events Updated incident reporting form attached
  to mailing.

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Reports of SREs to DPH as of 5/31/08

• 33 HOSPITALS HAVE REPORTED SREs
• 28 ACUTE CARE
• 4 REHAB
• 1 SUBSTANCE ABUSE
• 70 INCIDENTS REPORTED AS SREs OUT OF 351 HOSPITAL
  INCIDENT REPORTS

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SREs by Type as of 5/31/08
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Evidence of Under-reporting

• Monthly review
• March (falls only) 6 reported 28 potential
• April (all types) 11 reported 38 potential
• May (all types) 14 reported 16 potential
• DPH contacting hospitals on each potential
  SRE.

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Six month assessment highlights areas needing
attention

• To improve accuracy and consistency in reporting
  - Letter 08-06-489 sent 6/4/08
• Clarified serious disability.
• Clarified preventability not a determining factor
  of individual event.
• To strengthen ease of reporting
• Report form being redesigned
• Electronic reporting in process

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Per NQF What is Serious?

• Serious describes an event that results in death
  or loss of a body part, disability or loss of
  bodily function lasting more than seven days, or
• still present at the time of discharge from an
  inpatient healthcare facility or,
• when referring to other than an adverse event, an
  event the occurrence of which is not trivial.

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Other mid-year steps

• Race and ethnicity data on patients to be added
  to revised form (achieving QCC goal) by August,
  2008

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Increase Focus to Falls Prevention Current
activities lay groundwork for intensified approach
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Preliminary Efforts on Race and Ethnicity from
BORIM
Known Cases from 2005 Hospital Discharges
Known Cases from BORIM
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Potential action steps around falls

• Contract with Coalition for the Prevention of
  Medical Errors to provide education, training and
  TA to hospitals on falls prevention
• Require hospitals to submit plans regarding falls
  to DPH for review, evaluation and public posting
• Analyze circumstances surrounding falls for
  report to QCC and PHC

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Coordination with BORIM

• Goal Single access point for reporting
• Current Activity - Contract with consulting firm
  to develop business requirements for new
  web-based system
• Current Activity Planning for a manual system
  for sharing of root cause analyses with DPH

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SREs at PCA

• 214/826 total reported adverse events were SREs
  (26)
• Falls accounted for 118 or 55 of the SREs
• Falls with fracture (99) represented 84
• Wrong site/patient/procedure represented 22 of
  SREs
• Only 11 of the 28 SREs were reported.

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SREs Reported to PCA--2007
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SREs Reported to PCA--2007
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SREs Reported to PCA--2007
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Sharing RCA

• Developed a form for public reporting of RCA
• Have requested input about the form from
  hospitals
• Ready to explain goals of shared learning to
  stakeholder groups
• Developing a process with DPH for collecting RCA