Adverse Events Reporting:
How do consumers fit in?
February 20, 2008
Stratis Health
Community Outreach Committee
Update on Adverse Events
‘Background on Adverse Events
‘What’s happening?
‘Why is this important to me?
‘What happens next?
The road to adverse events reporting ‘ Institute of Medicine
(2000)
– 44,000 – 98,000
deaths every year
from medical errors
– Not many people
were aware of this
issue
The road to adverse events reporting ‘Minnesota Alliance for Patient
Safety
– Health Department
– Hospital Association
– Medical Association
‘Every event represents a real
person.
Goals of the law
‘Not …to punish errors by doctors,
nurses, or other healthcare
providers.
‘Instead…
– to hold people and organizations
accountable for problems
– To learn as much as we can about how to prevent these events.
Minnesota’s Law
‘Hospitals (2003)
‘Boards (2003)
‘Outpatient
surgical centers
(2004)
‘28 events that
shouldn’t happen
Examples of reportable events
(from list of 28 “never events” created by National Quality Forum)
‘ Surgical Events
– Wrong surgery
– Foreign object left in
the body
‘ Product or Device
– Contaminated drugs
or blood
– Product/device
malfunction
‘ Patient Protection
– Suicide or attempted
suicide
– Patient elopement
‘ Care Management
– Serious medication
error
– Death from
hypoglycemia
– Very serious bedsores
‘ Environmental Events
– Patient burns
– Patient falls
‘ Criminal Events
– Abduction
– Sexual assault
We’re not alone…
5
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How often do events happen?
Reported adverse events, 2003-2007
160
100
40
Reported events, Oct 2006-Oct 2007
125 Events
43 Bedsores
25 Objects
left in body
How serious are these events?
13 deaths, 10 serious disabilities
Why do they happen?
Why do they happen?
‘Communication
–
–
–
–
“I thought you were going to do it”
“Does that say 10 units or 1 unit?”
“I said to give her four, not fourteen”
“Don’t you remember? I told you as I
was leaving.”
Why do they happen?
‘Organizational culture
– “I didn’t want to say anything”
– “I’m sure he knows what he’s doing”
– “If I say something and I’m wrong,
people will get mad at me”
– “We’re in a hurry, there’s no time to
check the form again”
Why do they happen?
‘Policies
– “Who’s supposed to call for the timeout?”
– “I usually do that, but I was too busy
and I forgot”
– “We don’t do it that way in this unit”
Why do they happen?
‘Mistakes are inevitable
‘Usually not one person at fault
‘System has to
keep those
mistakes from
reaching you
Why do they happen?
Am I at risk?
‘Last year, there were 125 events.
– In the same time, thousands of people
were admitted to MN hospitals.
– They were there for a total of 2.8 million days.
‘Odds:
– 45 events per 1 million days.
– 4.6 deaths per 1 million days.
Does it matter?
YES!
Why this is important to you
‘Many pieces in the puzzle:
–
–
–
–
–
–
A doctor and hospital you trust
Quality of care
Cost
Patient safety
Insurance coverage
Location
Why this is important to you
‘What does patient safety look like?
–
–
–
–
–
–
–
–
Handwashing
Surgical site marking Verification of surgery/procedure
Patient identification
Regular turning & skin inspection
Fall prevention
Informed consent
Other best practices
Why this is important to you
‘Those steps need to happen every
time.
‘Watch for best practices.
‘Ask questions.
– How will you keep me from falling?
– What do you do to make sure my
surgery is right?
How can I learn more?
‘Annual report each January
‘Consumer guide
‘Website w/ searchable database
www.health.state.mn.us/patientsafety
How can I learn more?
‘ www.mnhospitalquality.org
‘ www.mnhealthcare.org (clinics)
‘ www.healthcarefacts.org
‘ www.minnesotahealthinfo.org
What comes next?
‘ Are we safer now than
we were?
‘ What do patients and
families need to know?
‘ What’s the best way to
share this information?
Keep looking…and learning
Questions?
Diane Rydrych
MN Department of Health
651/201-3564
[email protected]