Adverse Event Reporting: 5 years later, where are we?
Diane Rydrych
Assistant Director
Division of Health Policy
Minnesota Department of Health
[email protected]
651-201-3564
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How often do events happen?
Reported Adverse events, 2003-2008
Reported events, Oct 2007-Oct 2008
Retained
objects
37
Falls
95
Wrong site
surgery 21
Wrong
procedure
16
122 Bedsores
95 Falls
Medication Errors
6
Other
15
312 Events
Pressure
ulcers/bedsores 122
37 Objects
left in body
How serious are these events?
Death
6%
Serious
Disability
31%
Treatment/
Monitoring
55%
No Harm
10%
18 deaths, 98 serious disabilities
Impact of definitional changes
Pressure Ulcers by Outcome
Stage 3/4
29%
Unstageable
71%
Falls by outcome
Death
10%
Serious
disability
90%
What we’re learning: Falls
40%
37%
30%
29%
20%
10%
11%
6%
0%
Between From Bed
bed and
bathroom
From
chair
11%
6%
In
Outside pt
bathroom
room
Other
What we’re learning: Falls
Falls by Tim e of Day
25%
20%
15%
22%
18%
16%
14%
10%
18%
13%
5%
-m
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0%
What we’re learning: Pressure Ulcers
Pressure Ulcers by Age
65-74 years
23%
< 18 years
7%
19-39 years
7%
> 75 years
25%
40-64 years
38%
Pressure Ulcers
‘ Identifying Issues
–
–
–
–
complicated cases
multiple co-morbidities
trauma long surgeries ‘ Implementing learning
– hourly rounding
– education – comprehensive, aggregate analysis
What we’re learning: Surgery
Location of Wrong Site
Surgeries/Invasive Procedures
Diagnostic/
Lab
8%
Ambulatory
Surgery
19%
Other
15%
Radiology
15%
OR
43%
What we’re learning: Surgery
‘ OR schedule/consent matched: 15.5% No
‘ Surgeon signed site with initials 50.0% No
‘ Verbal participation in time-out
46.5% No
‘ Every step followed
15.5%
Wrong Site Surgery
‘ Identifying Issues
–
–
–
–
Procedural areas
Rote performance, staff not engaged
Inconsistent implementation of policies
Flawed time-out process
‘ Implementing learning
– Time out and site marking recommendations
– Education/training/video
– Follow-up observations
After all this………
..…..are we safer?
5 Year Evaluation
‘Focus Groups
– Hospitals, ASC’s
‘Online Survey
– Patient safety and QI
officers/managers
‘CEO Interviews
– Large/small/medium hospitals
Are we safer?
Prioritizing Patient Safety
Best Practices
Sharing Information
“Now I always ask the question,
‘Have you talked to your
colleagues around town about
ways they’ve been successful in this
area?’ The ability to dialogue was
made easier; it’s no longer a taboo
topic.”
Sharing Information
“(The reporting system) was able to
identify issues before they
happened so when … something
had happened at five facilities but
it hadn’t happened at yours yet, it
gave us an opportunity to address
issues before they even occurred.”
Leadership Involvement
“(The report) certainly is a required
conversation every CEO must have
with the board every year. If there
wasn’t a good conversation about
patient safety and quality with the
board every year before, this
required it.”
Leadership Involvement
“I would never have broached that
subject [patient safety] myself if the
law hadn’t been passed; I wouldn’t
have brought it to the board level.”
“The board spends as much time on
safety as on finance.”
Leadership Involvement
“Starting with myself, I’ve 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 to…what a
difference this makes in the quality of
care people receive. We’re now
talking about it at every level in the
organization, everyone from
housekeepers and dietary to
leadership and board members.”
Overall Assessment
“It’s really raised the bar.
I’m proud to say that.”
Overall Assessment
“The law opened people’s
consciousness up to looking
at things we wouldn’t have
looked at in a systematic
way before.”
Going forward
‘Make sure review process is timely,
constructive
‘Provide more analysis/data – but in a
meaningful way
‘Provide resources on strategies for
engaging leadership, assessing culture
‘Promote physician & consumer
engagement