eValue8 Community Forum:

1
Five Years of Adverse Events Reporting What
Have we Learned?
February 2, 2009
eValue8 Community Forum Patient Safety Diane
Rydrych Director, Adverse Health Events
Program Minnesota Department of Health Julie
Apold Director, Patient Safety Minnesota Hospital
Association
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Reported Events
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Reported events, Oct. 2007-Oct 2008
312 Events
122 Bedsores
95 Falls
37 Objects left in body
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Impact of definitional changes
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How serious are these events?
18 deaths, 98 serious disabilities
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Why do they happen?

• Communication
• Written, oral communication or lack
• Handoffs and transitions
• Organizational culture
• Speaking up
• Trust
• Policies
• Lack of clarity
• Lack of a policy

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Efforts to Prevent Events

• Focus on top four event types
• Wrong Body Part Surgery
• Retained Foreign Objects
• Falls
• Pressure Ulcers

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Determine Best Practices

• Minnesota Protocols Addressing AHE
• Pressure Ulcer Assessment and Prevention
• Foreign Object Retention
• Surgical Protocol
• Labor and delivery Protocol
• Safe Site Surgery Protocol
• Protocol builds on Joint Commission protocol
• Revision includes signing of site by surgeon with
  initials
• Falls Prevention Protocol

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Implementation

• Protocol ? Practice
• Statewide approach to implementing best practices
• Calls-to-Action
• Safe Skin
• Safe from Falls
• Safe Site
• Safe Count

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Calls-to-Action - Structure

• Implementation roadmaps
• Best Practice Steps
• AHE Learnings
• SAFE Infrastructure
• Teams, data, staff and patient education
• SKIN, Falls, Site, Count Patient Care Bundle

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Calls-to-Action - Process

• CEO Call to Participate
• Kick-off Event
• Baseline Survey Data
• Plan 1st Quarter Actions
• Submit Roadmap data quarterly and develop actions
  for each quarter
• Calls scheduled every other month
• Listserv
• Toolkit

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Call-to-Action - Participation

• Safe Skin 93 Hospitals
• Safe from Falls 108 Hospitals
• Safe Site 113 Hospitals ASC
• Safe Count 64 Hospitals

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Call-to-Action Results

• Of participating facilities
• 91 process for every 2-hour repositioning for
  at-risk patients (51 baseline)
• 94 have an interdisciplinary falls prevention
  team (55 baseline)
• 97 have a system to alert staff to pt risk for
  falls
• 90 have a Safe Site physician champion (33
  baseline)
• 92 have a process to support any member of the
  team calling for a hard stop (56 baseline)

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Progress on Calls to Action
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Cycle of Learning Safe Site

• In 2008, information from reported events led to
• Statewide recommendations and implementation
  support for conducting an effective time-out
  process
• Specific recommendations for marking anesthesia
  procedures such as regional blocks
• Collaboration between hospitals and clinics to
  develop a more standardized approach for
  scheduling and verifying procedures.

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5 Years Later What have we Learned?

• Collaboration Works
• No re-inventing the wheel
• Colleague Support
• Thinking outside the box
• Targeted implementation Works
• Laying out an implementation plan
• Making adjustments over time
• Transparency Works
• Tracking progress
• Sharing experiences moves safety efforts forward
  exponentially

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5 Years Later What have we Learned?

• This is hard work!
• Digging deeper is imperative
• Long-term vs. Short-term efforts
• We have addressed the low-hanging fruit left
  with the tough stuff
• Culture
• Physician Engagement
• Team Work
• Human Factors

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• After all this
• ....are we safer?

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5 Year Evaluation

• Focus Groups
• Hospitals, ASCs
• Online Survey
• Patient safety and QI officers/managers
• CEO Interviews
• Large/small/medium hospitals

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Are we safer?
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Prioritizing Patient Safety
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Best Practices
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• Its really raised the bar. Im proud to say
  that.

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Sharing Information

• Now I always ask the question, Have you talked
  to your colleagues around town about ways theyve
  been successful in this area? The ability to
  dialogue was made easier its no longer a taboo
  topic.

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Sharing Information

• (The reporting system) was able to identify
  issues before they happened so when something
  had happened at five facilities but it hadnt
  happened at yours yet, it gave us an opportunity
  to address issues before they even occurred.

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Leadership Involvement

• (The report) certainly is a required
  conversation every CEO must have with the board
  every year. If there wasnt a good conversation
  about patient safety and quality with the board
  every year before, this required it.

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Leadership Involvement

• I would never have broached that subject
  patient safety myself if the law hadnt been
  passed I wouldnt have brought it to the board
  level.
• The board spends as much time on safety as on
  finance.

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Leadership Involvement

• Starting with myself, Ive changed. Before this
  time, I thought we were doing a great job, we had
  a quality person in place. But I really sat up
  and paid attention towhat a difference this
  makes in the quality of care people receive.
  Were now talking about it at every level in the
  organization, everyone from housekeepers and
  dietary to leadership and board members.

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Overall Assessment

• The law opened peoples consciousness up to
  looking at things we wouldnt have looked at in a
  systematic way before.