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Carolyn M. Clancy, MD Director Agency for Healthcare

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Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality 5th Annual Colorado Patient Safety Conference November 11, 2005 Medical Errors in History ... – PowerPoint PPT presentation

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Title: Carolyn M. Clancy, MD Director Agency for Healthcare


1
Initiatives to Improve Quality and Safety in
Health Care
Carolyn M. Clancy, MD Director Agency for
Healthcare Research and Quality 5th Annual
Colorado Patient Safety Conference November 11,
2005
2
Medical Errors in History
  • In my opinion, physicians kill as many people as
    we generals.
  • -- Napoleon Bonaparte
  • The physician can bury his mistakes, but the
    architect can only advise his client to plant
    vines.
  • -- Frank Lloyd Wright, New York Times, 1953

3
Patient Safety Initiatives
  • To Err Is Human - 6 years later
  • AHRQ role and resources
  • Where we are today
  • Federal initiatives
  • Safety in numbers collaboration and
    communication

4
To Err Is Human
  • Landmark 1999 Institute of Medicine report
    elevated national awareness on issue of patient
    safety
  • Two key conclusions --
  • Traditional name, blame and shame response
    ineffective in improving safety
  • Safe, high quality care requires a team effort
    and significant communication and collaboration

5
Progress Since 1999
  • Regulation JCAHO safe practices
    standardization of practices A-
  • Workforce and Training PSIC maintenance of
    certification leadership training B
  • Error Reporting Systems C
  • Information Technology B-
  • Malpractice D
  • R Wachter. The end of the beginning patient
    safety five years after To Err is Human. Health
    Affair 2004 W4 534-545.

6
More Medical Errors in U.S.
Any medical mistake, medical error or test error
in last 2 years
2005 Commonwealth Fund International Health
Policy Survey
7
Incorrect Lab/Diagnostic Test
or Delay in Receiving Abnormal Test Result, Past
2 years
Percent reporting either lab test error
2005 Commonwealth Fund International Health
Policy Survey
8
Mistake/Medication Error/Lab Error
By Number of Doctors Seen in Past 2 Years
Percent
2005 Commonwealth Fund International Health
Policy Survey
9
AHRQ Research Study Critical Care Safety
  • Major Finding Patients face a significant risk
    for preventable adverse events and serious
    medical errors in hospital critical care units
  • In a study of patients admitted to intensive care
    units
  • 20 had an adverse event
  • 45 of the adverse events were
    preventable
  • Over 90 of incidents occurred
    during routine care

JM Rothschild, CP Landrigan, JW Cronin, et al.,
The critical care safety study the incidence and
nature of adverse events and serious medical
errors in intensive care, Critical Care Medicine.
33(8)1694-1700, August 2005.
10
Medical Errors and Nurse Fatigue
  • Patients are more at risk when nurses work
    long hours. A tired nurse is more likely to miss
    subtle changes, have more difficulties
    concentrating, and may not catch their own or
    others errors.
  • Ann Rogers, Ph.D. R.N.
  • University of Pennsylvania

AHRQ-funded grant HS11963
11
ICU Infections Down Nearly 80
  • Keystone initiative significantly reduced
    infections at 77 Michigan hospitals
  • Simple interventions hand washing reminders and
    elevating a patients head while on a ventilator
  • Project so successful that 68 ICUs had no
    infections or ventilator-associated pneumonias
    during the 18 months of the project

AHRQ-supported Pronovost study, 10/05
12
Colorado Physician and Public Agreement on
Medical Errors
Source Robinson AR, et al., Arch Intern Med,
2002 1622186-2190
13
Major Themes Identified at National Research
Summit
  • Epidemiology of Errors
  • Infrastructure to Improve Patient Safety
  • Information Systems
  • Knowing Which Interventions Should Be Adopted
  • Facilitating the Implementation of What is Shown
    to Work in Improving Safety
  • Disseminating Information to Clinicians,
    Policymakers, Patients, and Others

14
Patient Safety Initiatives
  • To Err Is Human - 6 years later
  • AHRQ role and resources
  • Where we are today
  • Federal initiatives
  • Safety in numbers collaboration and
    communication

15
AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
16
HHS Organizational Focus
NIH Biomedical research to prevent, diagnose and
treat diseases
17
HHS Organizational Focus
NIH Biomedical research to prevent, diagnose and
treat diseases
CDC Population health and the role of
community-based interventions to improve health
18
HHS Organizational Focus
NIH Biomedical research to prevent, diagnose and
treat diseases
CDC Population health and the role of
community-based interventions to improve health
AHRQ Long-term and system-wide improvement of
health care quality and effectiveness
19
AHRQ and Patient Safety
  • Identify medical errors and other threats to
    patient safety and understand why they occur
  • Advance knowledge of practices that will reduce
    or eliminate the occurrence of medical errors and
    minimize risk of patient harm
  • Develop, assemble and disseminate information on
    how to implement best practices for patient
    safety
  • Enable providers to monitor and evaluate threats
    to patient safety and the progress being made

20
Safety Research Training
  • Funded over 225 patient safety and related health
    information technology projects since 2001
  • Awarded over 8 million in funding for 15
    Partnerships in Implementing Safety
  • Patient Safety Improvement Corps
  • New curriculum under development by AHRQ,
    Department of Defense, CMS and Quality
    Improvement Organizations

21
Advances in Patient Safety From Research to
Implementation
  • Four-volume set of 140 peer-reviewed articles
    representing an overview of patient safety studies

22
Advances in Patient Safety
Volume One
  • Focuses on research that demonstrates solid,
    broad and rapid progress
  • Includes articles on state-of-the-art detection
    and tracking systems
  • Examines interventions that address adverse drug
    events
  • Explores building a culture of safety

23
Advances in Patient Safety
Volume Two
  • Covers concepts and examines complex systems of
    care
  • Shows how providers can move past the name, blame
    and shame approach to improving safety by
    focusing on system improvement and human factors

24
Advances in Patient Safety
Volume Three
  • Covers implementation issues and identifies
    barriers to diffusion of patient safety
    improvements and approaches to changing cultures
  • Implementation issues are where its at for
    patient safety -- Lucian Leape

25
Advances in Patient Safety
Volume Four
  • Showcases programs and products, screening tools
    and process simulators
  • Provides details on how to overcome barriers to
    success
  • Not just the tools but in many cases the
    equivalent of an instruction manual Mary
    Wakefield

26
AHRQs Patient Safety Network (PSNet) on the Web
  • PSNet is a national one-stop portal of
    resources for improving patient safety and
    preventing medical errors
  • Offers wide variety of information on patient
    safety resources, tools, conferences, and more
  • Diverse users can customize the site around their
    unique interests and needs by creating a My
    PSNet page
  • Website http//psnet.ahrq.gov

27
AHRQ Web MM
  • AHRQ Morbidity and Mortality website Identifies
    problem areas and potential solutions
  • Shares new cases and expert commentaries
  • Monthly spotlight case with educational slide set
  • Over 28,000 visitors per month
  • Website http//webmm.ahrq.gov

28
Hospital Survey on Patient Safety Culture
  • New tool helps hospitals and health systems
    evaluate employee attitudes about patient safety
    in their facilities or within specific units
  • Includes survey guide, survey, and feedback
    report template to customize reports
  • AHRQ partnership with Premier, Inc., Department
    of Defense, and American Hospital Association
  • www.ahrq.gov/qual/hospculture/ or e-mail
    hrqpubs_at_ahrq.gov

29
Educating Patients, Too
30
Patient Safety Initiatives
  • To Err Is Human - 6 years later
  • AHRQ role and resources
  • Where we are today
  • Federal initiatives
  • Safety in numbers collaboration and
    communication

31
Where We Are Today
  • Substantial momentum and activity
  • New legislation that eliminates strong
    disincentives to improving patient safety
  • Continued public interest
  • Weak business case
  • Impossible to know whether safety has improved
    or not
  • Is the time right to shift from research and
    voluntary action to bold goals?

32
Reporting and Surveillance Systems
Active Reporting Systems
Indicators From Administrative Data
Medical Record Monitoring Systems
33
Physicians Identified Barriers to Successful
Error Reduction
  • Difficulty in defining errors
  • More training in handling errors
  • Who should report errors and have access to
    results
  • Fear of malpractice litigation
  • Need for greater legal safeguards

Source Robinson AR, et al., Arch Intern Med,
2002 1622186-2190
34
Where We Are Today
  • Implementing patient safety legislation
  • Requires detailed assessment of existing
    measurement systems
  • Bill includes mandate for GAO evaluation in 2010
  • New opportunities for improving safety
  • MMA ? increased focus on medication safety
  • Ambulatory care urgent need to decrease errors
    due to poor coordination

35
Possible Goals
  • Reduce medication errors by 50
  • Reduce high-harm errors by 90
  • Reduce nosocomial infections
  • Reduce errors due to lost tests, results by 50
  • Others

36
Next Steps
  • Identify candidate measures and data sources
  • Review of existing measures
  • Errors, harms, and/or safe practices?
  • Broad public call
  • Establish baselines
  • Collaborate with stakeholders
  • Partnership with NQF

37
Patient Safety Initiatives
  • To Err Is Human - 6 years later
  • AHRQ role and resources
  • Where we are today
  • Federal initiatives
  • Safety in numbers collaboration and
    communication

38
AHRQ Health IT Research
  • Promote access to Health IT
  • Over 166 million investment to date
  • Over 100 grants to communities, hospitals,
    providers, and health care systems to help in all
    phases of the development and use of Health IT
  • Grants spread across 43 states
  • Special focus on small and rural hospitals and
    communities.

39
Health IT Opportunities
  • Reengineer processes to improve patient
    safety
  • As we migrate to a health IT infrastructure, put
    effective processes in place as the same time
  • Augment health IT applications for error
    reduction, CPOE and other decision support tools
  • Build in the necessary disciplines and team
    approaches

40
Health IT and Patient Safety
Key challenges
  • Tap and collect ongoing resources
  • Convince clinicians to buy in
  • Understand existing workflow
  • Understand HIT impact on workflow
  • Data standards/integration
  • Get vendors to make needed changes

41
Building HIT Evidence Base
  • Electronic Health Records
  • Clinical Decision Support
  • Electronic Prescribing
  • Use of hand-held devices
  • AHRQ National Resource Center on Health
    Information Technology

42
HIT, Quality and Safety
  • Outpatient Advanced CPOE and EMR
  • Avoid 2.1 million adverse drug events
  • Inpatient CPOE and EMR
  • Decrease serious medication errors by 55
  • Healthcare information exchange and
    interoperability between settings
  • Improve decision-making at the point-of- care
    through complete information access

Source CITL
43
AHRQ Research Study CPOE
  • Major Finding While computerized physician order
    entry (CPOE) is expected to significantly reduce
    medication errors, systems must be implemented
    thoughtfully to avoid facilitating certain types
    of errors
  • Study looked at clinicians experience in using
    one CPOE system at a major urban teaching
    hospital
  • Implementation problems can be minimized through
    testing before products are marketed and through
    adaptation to meet the needs of individual
    clinical settings

R. Koppel, J. Metlay, A. Cohen, et al., Role of
computerized physician order entry systems in
facilitating medication errors, Journal of the
American Medical Association, March 9, 2005
44
E-Prescribing Standards
  • Contracts administered by AHRQ on behalf of
    Centers for Medicaid and Medicare Services
  • Pilot testing of electronic prescribing standards
    and how they interact with e-prescribing workflow
  • Testing will be conducted during 2006
  • Results will be reported to Congress in 2007 and
    used to develop final e-prescribing standards

45
Low Health IT Adoption Rate
  • Only 14.1 percent of all medical group practices
    use an electronic health record
  • Only 12.5 percent of practices with five or fewer
    FTE physicians have EHRs

AHRQ contract 290-00-0017 University of
Minnesota
46
Patient Safety Act of 2005
  • Creates Patient Safety Organizations (PSOs)
  • Establishes Network of Patient Safety Databases
  • Mandates Comptroller General to study
    effectiveness of Act (by 2010)
  • Is completely voluntary

47
Legislation Goals
  • Encourage providers to identify correct medical
    errors threats to patient safety by ensuring
    that their work with PSOs cannot be used against
    them in courts or in disciplinary proceedings
  • Encourage aggregation of cases by among PSOs,
    creating a network of patient safety databases

48
Patient Safety Organization
  • Private or public entity
  • Meets PSO criteria complies with
    policies/procedures
  • Self-certifies initially every 3 years
    thereafter
  • Certification is accepted by Secretary or not
    may be revoked

49
PSO Criteria
  • Mission to improve quality safety
  • Has appropriately qualified staff
  • Within 24 months of listing, has contracts with
    more than 1 provider
  • Is not part of a health insurer
  • Collects data in standardized manner
  • Uses work product to provide feedback
    assistance minimize patient risk

50
PSO Activities
  • Conducts efforts to improve patient safety
    quality
  • Collects analyzes data, reports, records, root
    cause analyses
  • Develops/disseminates information to improve
    patient safety
  • Encourages culture of patient safety
  • Maintains procedures to keep work product
    confidential

51
Patient Safety Databases
  • Interactive evidence-based management resource
  • Capacity to accept, aggregate, analyze
    voluntarily reported non-identifiable data
  • Data to be used to analyze national regional
    statistics, including trends patterns of health
    care errors
  • Information to be reported annually (National
    Healthcare Quality Report)

52
Patient Safety Initiatives
  • To Err Is Human - 6 years later
  • AHRQ role and resources
  • Evidence of progress
  • Federal priorities
  • Safety in numbers collaboration and
    communication

53
  • 2,600 hospitals implementing changes in care
    proven to prevent avoidable deaths
  • Interventions include rapid response teams,
    evidence-based care for acute myocardial
    infarction, and prevention of adverse drug
    events, central line infections, surgical site
    infections and ventilator-associated pneumonia

54
SCIP Collaboration
  • Surgical Care Improvement Program (SCIP)
  • Collaboration between AHRQ, Centers for Medicare
    Medicaid Services, the Centers for Disease
    Control and many private sector partners
  • Initiative designed to eliminate surgical
    complications such as postoperative pneumonia and
    surgical site infections

55
On the Road to Safety
Have you ever noticed....anybody going slower
than you is an idiot, and anyone going faster
than you is a maniac? George Carlin
56
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