Adverse Events in Maryland: A Positive Culture of Reporting Through the MPSC Software

Transcription

1 Adverse Events in Maryland: A Positive Culture of Reporting Through the MPSC Software Fourth Annual Maryland Patient Safety Center Conference Vahé A. Kazandjian, PhD, MPH President, LogicQual Research Institute Member, MPSC Board of Directors March 20, 2008 Vivian Miller, BA, LHRM, CPHQ, CPHRM, FASHRM Research Project Manager Maryland Patient Safety Center Frank Pipesh Senior Director, Information Technology Center for Performance Sciences The Maryland Patient Safety Center is an organization that received the Joint Commission/National Quality Foundation John Eisenberg Award for Excellence in 2005 WITHOUT having collected data! Indeed, it was its structure and goals that were significantly different from any other safety organization in the country. 1

2 For the past year, the Maryland Patient Safety Center has been collecting data after careful planning of what should be collected; ways to collect these; and, what difference it can make to quality/safety of care The tools and methods of data collection and analysis have already been adopted by Maryland hospitals, and a trend of performance data already identified. Today, we would like to share GOOD NEWS about that!! So, let s re-cap. 2

3 The Maryland Patient Safety Center (MPSC) The MPSC is the organization where data play an important role, but only as a facilitator for services to health care organizations. Indeed, the data is now being used to identify areas of common need for improving safer practices and tailoring programs (services to assist hospitals and other care providing organizations). Today s discussion is about the progress we have made in the last year! It is also about analyzing key aspects of structures, processes, and outcomes of care that have direct implications to safety of care and eventually, to accountability. 3

4 The implementation phase has revealed some patterns and trends about events occurring in health care organizations. Please remember, we are from the Incident Reporting System (IRS) and we are here to help you! Here s a brief overview of how data is entered into the system. The Maryland Patient Safety Center s Web-based Incident Reporting System The Maryland Patient Safety Center s Reporting System is: Voluntary reporting of any/all adverse patient events. The Maryland State Department of Health and Mental Hygiene s Office of Health Care Quality requires: Mandatory reporting of all Level 1 Events to the OHCQ whenever it has been determined that the organization most likely contributed to the serious and/or permanent injury, illness or death of a patient. 4

5 The Maryland Patient Safety Center s Web-based Incident Reporting System Designed to report all incidents, particularly those near miss events that seem to occur repeatedly Track and trend events based on: high cost high volume high risk Problem prone Determine organizational priorities Focus efforts toward improving processes Promote safer practices Pilot Participants Total Number of Participating Hospitals/Healthcare Facilities 31/47 Number of Participating Facilities to use MPSC s Adverse Event Reporting Tool to Date 7 currently using tool Number of Participating Facilities to Submit Data to Date 24 5

6 Participants Actively Using System Chester River Hospital Center Western Maryland Health System Braddock Campus Memorial Campus Frostburg Nursing and Rehabilitation Center Nanticoke Memorial Hospital (DE) Fort Washington Medical Center Facilities Submitting Data University of Maryland Medical System University of Maryland Medical Center Baltimore Washington Medical Center Shore Health System Memorial Hospital at Easton Dorchester General Hospital Maryland General Hospital University Specialty Hospital Mount Washington Pediatric Hospital Kernan Orthopaedics & Rehabilitation Upper Chesapeake Health Harford Memorial Hospital Upper Chesapeake Medical Center Carroll Hospital Center Atlantic General Hospital Garrett County Memorial Hospital Union Hospital of Cecil County St. Mary s Hospital MedStar Health Franklin Square Hospital Center Good Samaritan Hospital Harbor Hospital Center Union Memorial Hospital LifeBridge Health Sinai Hospital Northwest Hospital Center 6

7 The Maryland Patient Safety Center s Web-based Incident Reporting System Reminder that the tool is offered AT NO COST TO THE FACILITY. The tool was designed to satisfy more than one organizational need. Multi-facility systems Long Term Care Home Health In fact, as the tool continues to be piloted, improvements are made every day based on user suggestions and recommendations. The Maryland Patient Safety Center s Web-based Incident Reporting System A reminder.use of the system is voluntary, but if your facility agreed to participate in the pilot, we need you to submit your data to the MPSC. 7

8 What are we seeing from the data collected? Data types: Systematic and defined for standard reporting purposes Free text for data mining opportunities In cide nt T yp es P ercen tag e R ep o rt Re p ort Da te : Tue sda y M a r 20, 2007 Num b e r o f Incid e nts: 622 DO NOT CITE WITHOUT PERMISSION Incid e nt Type Coun t Ha rm No Ha rm Don 't Kno w % of #Incide n t O ther N/A (Not Assigned) M edications Falls Laboratory Com m unic ation P rovisioncare S urgic al Unexpected Departure from Facility E quipm ent Cons ent Radiological A s sault B lood-transfus ion Unex pec tedrem oval B urn Drug Environm ent of care Nutrition O bs tetric s Restraints UnanticpatedDeath

9 Incident Report Data by Type and by Harm vs. No Harm 110/18% Medications Medications Falls 343/55% Other 90/14% Falls Laboratory Communication 30/5% Laboratory ProvisionCare Other 27/4% Communication 22/4% Provision of Care 9

10 Inc ident Re port Da ta by Type a nd Ha rm vs. No Ha rm Num ber = through February 6, /3% Communication Adverse Drug Rx Unexpected Departure from Facility 237/3% Medical Records 244/3% Me d ica tio n s O th e r Fa lls L a b o ra to ry 378, 5% Provision of Care 348/5% 1579/22% Medication P ro vis io n C a re M e dica l Re c ords 532/7% Laboratory U n e xpe cte d D e pa rtu re from Fa cility 886/12% Falls 1208/17% Other C o m m u n ica tio n D ru g What s Next? Analysis of definitive patterns and trends among facilities. Maryland Patient Safety Center to work with hospital patient safety officers and the Institute for Safe Medication Practices (ISMP) to develop standardized best practice patient safety prevention processes, based on trended data. 10

11 What s Next? Make recommendations about better practice models to all facilities. Collect information about the implementation of new strategies for safer practices. Provide comparative analysis across facilities to demonstrate the extent and nature of improvements statewide. 11