Learning from Patient Safety Events at the Patient

Learning from Patient Safety Events at the Patient Care Unit Level Peter G. Norton Professor Emeritus of Family Medicine University of Calgary May 7, 2010

The vital few Give me a fruitful error any time, full of seeds, bursting with its own corrections. You can keep your sterile truth for yourself. Vilfredo Federico Damaso Pareto (1848 -1923)

Background • We are constantly learning, but the issue is whether what we learn is correct • Associations between things that appear to be correlated may lead us to believe that they are causal, when in fact, they are unrelated; therefore, we need to find ways to go beyond seeing associations Using Adverse Event Data to Improve Quality of Care—Richard Cook, M. D.

• During the past 15 years, our understanding of how large, complex systems fail has changed • They fail in a particular way, that is, they have certain "signatures" • Multiple faults occurring together, rather than a single point failure, cause system failure; there is no single root cause • These small, otherwise innocuous, faults that exist in complex systems are termed latent failures Using Adverse Event Data to Improve Quality of Care—Richard Cook, M. D.

We know that. . . • most problems are not just a series of random, unconnected one-off events. • errors are provoked by weak systems and often have common root causes which can be generalized and corrected. • the similarities and patterns in sources of risk often go unnoticed if incidents are not reported analysed. • reporting of a serious event or “near-miss” should trigger an in-depth investigation to identify underlying systems failures and lead to efforts to redesign the systems to prevent recurrence

The response system is more important than the reporting system

Quality improvement reviews • Identify the causes of adverse events or close calls by looking at the system in which health care is provided • Can lead to system improvements that will prove beneficial to all future patients • Reviewer teams require – skills and knowledge in how to analyze unexpected outcomes – clinical expertise – ability to effect change in response to recommendations from the review • Review should be done as soon as reasonably practical, ideally within days of an event – optimizes recall of the facts – actions can be taken promptly From the CMPA

Which events should we choose to learn from?

The problem of numbers • The CAES established a lower bound of 3% (12% is probably close to reality) of patients having a preventable AE • A 40 bed unit with average LOS of 3 days will have over 90 different patients per week and so from the CAES more than 4 serious AE per week (in reality 16 or more)

The numbers – the study • 1006 hospital admissions between January and May 2004 in a large in England using standard retrospective chart audits • 22. 9% (231) of admissions had one or more serious PSE • ½ of these caused harm • only 21 were detected by the reporting system Sari A, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007 doi: 10. 1136/bmj. 39031. 507153. AE

Which events should we choose to learn from? ANSWER: - THOSE WITH THE MOST POTENTIAL FOR HARM? -THOSE MOST LIKELY TO OCCUR AGAIN? -THOSE MOST BOTHERSOME? -THOSE WITH THE LARGEST POTENTIAL FOR PUBLICITY? -. . .

The bottom line(s) are: 1. Capture as many as you can – the system must be simple and usable 2. Prioritize those for analysis and subsequent learning

One approach at the ORG level - LDS PSE Frequent Events ADE hospital acquired infections decubitus ulcers falls/restraints Detected by routine monitoring Recognized causes Unusual causes Rare events mechanical failure wrong side surgery suicide Detected through voluntary reporting Quality improvement review System improvement

Another possible way Possibly more applicable at the unit level

#1 – Apply VA Triage Questions • Was the event thought to be the result of: a criminal act – a purposefully unsafe act; – an act related to substance abuse by provider/staff; – or events involving suspected patient abuse of any kind (i. e. situations outside the scope of the risk management / quality improvement program)? • If yes, refer to applicable administrative processes

#2 – those left apply something like the NZ triage system • Determine severity – Serious/major/moderate/minor/minimal • Determine likelihood of recurrence • Assign SAC (severity assessment code) • Determine action required

Major • Clinical: Major permanent disability or loss of function (sensory, motor, physiologic or psychologic) unrelated to the natural course of the illness and differing from the expected outcome of patient management • Staff, contractor, visitor: Permanent disability or loss of function to staff member, contractor or visitor; requires major additional medical or surgical intervention • Finances: Cost overrun or reduction in revenue: the lower of >$2 M or > 7 -10% • Services: significant ongoing disruption to a key service; recommendations requiring action within 6 weeks

#2 – those left apply NZ triage • Determine severity – Serious/major/moderate/minor/minimal • Determine likelihood of recurrence • Assign SAC (severity assessment code) • Determine action required

Probability Certain Is expected to occur again either immediately or within a short period of time (likely to occur at least once in the next 3 months) Almost certain Will probably occur at least once in the next 4 -12 months Likely Is expected to occur within the next 1 to 2 years Unlikely Event may occur at some time in the next 2 to 5 years Highly Unlikely to recur – may occur only in exceptional circumstances ie 6+ years)

#2 – those left apply NZ triage • Determine severity – Serious/major/moderate/minor/minimal • Determine likelihood of recurrence • Assign SAC (severity assessment code) • Determine action required

NZ SEVERITY ASSESSMENT CODE Probability Consequence Serious Major Moderate Minor Minimal Certain 1 1 2 3 3 Almost certain 1 1 2 3 4 Likely 1 2 2 3 4 Unlikely 1 2 3 4 4 Highly Unlikely 2 3 3 4 4 http: //www. moh. govt. nz/moh. nsf/indexmh/improvingquality-reportableevents-resources

#2 – those left apply NZ triage • Determine severity – Serious/major/moderate/minor/minimal • Determine likelihood of recurrence • Assign SAC (severity assessment code) • Determine action required

Action Required 1 2 Extreme risk – immediate action required – A Root Cause Analysis (RCA) investigation must be completed within 70 calendar days. Reportable Event Brief (REB) must be forwarded to the national central agency High risk – senior management attention needed – Notification to the national central agency and a detailed investigation must be completed within 70 calendar days 3 Medium risk – All incident forms to be reviewed, review in common incident types may be most appropriate to develop a common action plan. Responsibility for management of these incidents must be assigned. 4 Low risk – manage through team level review and improvement procedures.

Exercise • Carry out the NZ process at your table for each of three cases as reported • Carry out the NZ process at your table for each of three cases considering the potential consequence rather than the reported one • Discuss the differences • Do you think this scoring system might help you prioritize PSE learning opportunities?

Case 1 – general medical ward In the morning nursing staff where showering an older patient. The patient was seated in a chair being washed when he slid off the chair and hit his face, hip and shoulder. There was no bleeding or LOC. The doctor examined the patient shortly after and x-rays were ordered. No fractures were noted. The patient returned to the ward where hourly neurological checks were initiated according to policy and these were reported as normal.

Case 2 - ICU A patient in the ICU developed cardiac arrhythmias but the monitor failed to trigger the alarm. The arrhythmia was observed by two nurses. As the patient had previously been determined to be not for resuscitation and so was not resuscitated.

Case 3 – Rehab service A patient was admitted to the rehab/stroke service following a massive stroke. During routine nursing it was noted that a tourniquet had been left on the patient’s arm after a blood test had been taken about 30 minutes before. The tourniquet was removed immediately; the hand was noted to be deep purple. On subsequent examination the patient’s arm and hand returned to normal appearance – it was warm and dry with good capillary return.

Case Consequences Likelhood SAC score Potential consequence Potential SAC score 1 - fall in shower Minor (additional tests) Likely 3 Serious 1 2 - ICU Minimal Unlikely 4 Serious 1 3 Rehab/stroke minor Frequent 6 reported in last year 4 Moderate 2

Mode 2 We invite you to help us move our research forward Why is this important?

Traditional model of KT Researchers produce new knowledge They publish, present at meetings Knowledge users The process either fails or is much too slow here

Mode 2 knowledge production • knowledge is generated within the context of application - the total environment in which scientific problems arise • trans-disciplinary - a range of theoretical perspectives and practical methodologies are brought to bare on the problems • broadened research communities • a dialogic process, an intense (and perhaps endless) ‘conversation’ between research actors and research subjects • novel forms of quality control emerge – e. g. what is a peer? Professor Michael Gibbons, MBE www. ncddr. org/kt/products/focus 21/Focus 21. pdf

The Canadian (CIHR) model is called integrated KT • a way of doing research • collaborative research, action-oriented, co-production of knowledge - engaging researchers and stakeholders (end -users) • involves integrating stakeholders into the entire research process study stakeholders can be: – investigators from different disciplines, teams, countries – policy makers, decision makers, research funders, the public, clinicians, the media (See Ian Graham, VP of KT at CIHR - http: //www. cihr-irsc. gc. ca/e/33747. html) • this workshop and its evaluation was funded as an integrated KT project

So this discussion is. . . • Part of an integrated KT strategy • To formulate our program for the future we need to begin the ‘conversation’ • We want to focus on learning from PSEs and: – (individually) think of 1 important problem where new knowledge would be helpful for you, than – (as a table) discuss what you each came up with and identify the two most pressing issues • Consider whether you might be interested in collaborating on a research initiative to examine a question

Conversation Activity • We want to focus on learning from PSEs • What are the important problems / most pressing issues – those where we need new knowledge? • [10 mins table discussion, followed by open room dialogue]