Adverse Event Monitoring as a Quality Improvement Driver: The Free State Case Study
Dr Sipho Kabane
Contents
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Introduction
South African context
WHA Resolutions
Free State Study: Aims and Objectives Design and Methodology
Interventions
Results
Discussion
Introduction
• IOM report 44 000 to 98 000 die as a result of adverse events in the USA in 1999
• These cost between $17 and $29bn p.a.
• Various international studies indicate that 10% of all hospital admissions associated with AE
• Medicines, wound sepsis and technical complications
• Between 35% and 50% preventable
South African Context
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Resource constrained environment
Burden of disease driven by HIV, AIDS & TB
Chronic Shortage of personnel
High patient: nurse ; High patient: Dr ratios
Long working hrs; Inappropriate skills mix
“Moonlighting” and RWOPS
Absence of clinical guidelines and protocols
Faulty, out‐dated equipment
Infrastructure that is falling apart
Poor Leadership and Stewardship
Poor waste management and Infection control
TH
WHO: [55
WHA‐2002]
Identified the following as urgent priorities:
• Development of common definitions and classification systems
• Placing patient safety high in quality agenda
• Development of a framework for measuring and reporting adverse events
• Establish research networks
• Establish partnerships between private and public sectors to address problem
Location of the Free State province in South Africa
Limpopo
Mpumalanga
North West
Gauteng
Free State
Kwa-Zulu Natal
Northern Cape
Eastern Cape
Western Cape
Aim of Study
The overall aim of the study is to determine if the development and implementation of a hospital clinical adverse events prevention programme will result in the improvement of the performance of hospitals in the Free State, South Africa.
Objectives of study
• To develop and implement a clinical adverse event management programme linked to an accreditation programme in public sector hospitals
• To determine the impact of the programme on
– the rate and severity of incidents – the overall quality of healthcare services
• To identify information categories to monitor incidents and adverse events that impact on patient safety
• Based on the findings, develop processes that will prevent and / or reduce the impact of incidents and adverse events on patient safety.
Quasi experimental study :
Randomly selected intervention and control hospitals in Free State
MRR to compare the AE pick‐up capacity with the MRR approach
MRR + patient and staff satisfaction surveys and staff safety culture surveys Jan 2008 to June 2010
MRR + patient and staff satisfaction survey and staff safety survey AIMS
12 Intervention hospitals 0
Months
9
30
12 Control hospitals
AIMS
MRR + patient and staff satisfaction and safety culture surveys (All hospitals were using COHSASA FAP programme at the start of the programme. The FAP measured performance in all services throughout the study)
Research Design
An interventional, quasi‐experimental study with intervention and control groups of hospitals. Hospital sampling
Total number of Free State provincial hospitals:
• 1 tertiary, 5 regional and 25 district hospitals.
Assumptions influencing sampling:
• Interventions involve entire hospitals so cluster randomisation will be used.
• Free State Adverse Event rate > reported 10% rate for developed countries (expected rate = +/‐ 18% due to high burden of disease and shortages of personnel and other resources). • Interventions will
– reduce severe incident rates per hospital.
– will reduce the adverse events rate by a minimum of 6% over a period nine months.
The resultant sample size:
• 24 hospitals comprising 12 intervention and 12 control hospitals.
Cluster randomisation of intervention and control hospitals
Selected strata:
1. District hospitals:
• Complex 1: six were chosen (from seven hospitals)
• Complex 2: six were chosen (from nine hospitals)
• Complex 3: six were chosen (from seven hospitals)
• Complex 4: two were chosen (from 2 hospitals)
2. Regional and tertiary hospitals:
• Four out of five hospitals were chosen Randomisation of strata:
• The hospitals in each stratum were randomly selected into two groups of 12, the intervention and control groups and matched according to bed numbers and the levels of care provided. Location of research hospitals in five
health districts of Free State
Northern Free State
Thabo Mofutsanyane
Lejweleputswa
Motheo
Control Hospitals
Intervention Hospitals
Xhariep
Free State Interventions
• Implementation of AIMS
• Development and implementation of Clinical Governance and Adverse Events Committees
• Establishment of Incident investigating teams
• Creation of a Event reporting and Just Culture
• Evidence‐based Continuous quality interventions
Advanced Incident Management System (AIMS)
A computerised system for monitoring, analysing, reporting and managing problems ranging from near misses to sentinel events across the entire spectrum of health care.
AIMS system
(off site)
Notifying incidents
Hospital staff phone in to call centre:
They are guided to provide detailed data specific to the incident by cascading questions
AIMS system
(off site)
Data
is entered
Takes +/- 7 minutes to
fully record an incident
which is immediately
emailed to hospital (or
phoned through if serious)
The computer system captures, classifies and grades clinical incidents, adverse
events and near misses.
Once alerted, hospital staff use the Internet to:
• access call centre data
• manage incidents.
Adverse events and near misses
Adverse event
YES
Adverse patient incident
"Any event or circumstance that could have, or did lead to, unintended or unexpected harm, loss or damage"
Did the incident result in harm,
loss or damage?
NO
Near miss
Free State Study:
Results‐ All Incidents
All Incidents reported to the AIMS call centre per month
by 100 000 PDE Jan 2008 – March 2010
Comparison of Intervention & Control hospitals
Intervention
Control
200
178
180
171
170
163
162
169 167
162
160
137
140
124
115 112
120
100
80
119
114
110
113
75
66
67
61
60
40
20
0
109
98
95
132
129
122
41
38
29
62
126
112
107
103
92
95
86
77
70 73
64
46
53 54
68
Free State Study: Results: All Incidents
Free State Study:
Results(AE/NM/RF)
Free State Study:
Results –Control vs Intervention Free State Results: Near Misses
Near Miss Incidents reported to the AIMS call centre per month
by 100 000 PDE Jan 2008 – March 2010
Comparison of Intervention & Control hospitals
Intervention
Control
45
41
40
35
29
30
25
27
25
20
20
0
16
14
13
12
10
10
5
18
17
15
15
22
22
10
9
88
3
7
4
4
4
2
3
8
6
3
2
2 3
3
22
3
5
2
3
2
Free State Results: Near Misses
Free State Study
Results: Adverse Events by PIT
Free State Study: Results‐ Clinical Management Free State Study: Result‐ MRR
14
12
10
8
6
4
2007
2008
2
0
Free State Results
MRR: Adverse Event Classification
MRR Adverse Events per 100 admissions by PIT
70
60
50
40
30
20
10
0
Free State Study
FAP scores: Intervention and Control
Free State Study
Service Element Scores: Intervention Sites
Free State Study
Service Element Scores: Control Sites
Mean Patient Satisfaction Rates: Intervention Sites
Mean Patient Satisfaction Rate: Intervention Sites
90
80
70
60
50
40
MSR 1
30
MSR 2
20
10
0
Mean Patient Satisfaction Rates: Control Sites
Mean Patient Satisfaction Rate: Control Sites
90
80
70
60
50
40
MSR 1
MSR 2
30
20
10
0
Free State Study:
Discussion and Conclusions
• Computerised Incident Management system increased incident and adverse event reporting
• More incidents and adverse event reported through AIMS compared to paper based system
• More incidents and adverse events reported through AIMS than captured through MRR
• Classification of incident and adverse event types is better through a computerised system
Free State Study:
Discussion and Conclusion
• Implementation of relevant structures, and the establishment of a “Just Culture”, improved incident and adverse event reporting
• There was an overall increase in patient satisfaction and quality accreditation scores in all hospitals over the study period
• The overall satisfaction and quality accreditation scores were more pronounced in the intervention compared to the control sites