Office of Health Care Quality 2016 Update on Hospital Adverse Events. Anne Jones RN, BSN, MA Nursing Program Consultant March 18, 2016

Transcription

1 Office of Health Care Quality 2016 Update on Hospital Adverse Events Anne Jones RN, BSN, MA Nursing Program Consultant March 18, 2016

2 Mission of OHCQ The agency within the Department of Health and Mental Hygiene charged with monitoring the quality of care in Maryland s 16,499 health care facilities and community-based programs. License and certify health care facilities. Conduct surveys to determine compliance with State and federal regulations. Educate providers, consumers, and other stakeholders.

3 Facilities and Programs Nursing Homes Intermediate Care Fac. for Individuals with Int. Dis. Forensic Residential Centers Assisted Living Programs Adult Medical Day Care Centers Dev. Dis., Day Habilitation Services Dev. Dis., Family and Individual Support Services Dev. Dis., Group Homes Dev. Dis., Intensive Treatment Programs Dev. Dis., Respite Services Hospitals Transplant Centers Freestanding Medical Facilities Health Maintenance Organizations Correctional Health Facilities Residential Treatment Centers Physician Office Laboratories Point-of-Care Laboratories Federal Waived Laboratories Independent Reference Laboratories Hospital Laboratories Cholesterol Testing Sites Tissue Banks Cytology Proficiency Sites Public Health Testing Forensic Laboratories Employer Drug Testing Birthing Centers Comprehensive Outpatient Rehabilitation Facilities Cosmetic Surgery Centers Freestanding Ambulatory Surgical Centers Freestanding Renal Dialysis Centers Home Health Agencies Hospices Hospice Houses Major Medical Equipment Outpatient Physical Therapy Portable X-ray Providers Residential Services Agencies Surgical Abortion Facilities Group Homes for Adults w/ Mental Illness Mental Health Vocational Programs Ambulatory Detoxification Programs Nurse Referral Agencies Health Care Staff Agencies Mobile Treatment Services Outpatient Mental Health Centers Psychiatric Rehabilitation Programs, Adults Psychiatric Rehabilitation Services, Minors Psychiatric Day Treatment, Partial Hospitalization Residential Rehabilitation Programs Residential Crisis Services Respite Care Services Therapeutic Group Homes Therapeutic Nursery Programs Opioid Maintenance Therapy Programs Outpatient Treatment Programs Residential Programs Education Programs Residential Detoxification Treatment Programs Correctional Substance Abuse Programs 3

4 Objectives Understand FY15 trends in reported adverse events Discuss case studies of selected reported events. Understand causative factors and how to implement effective and lasting corrective actions.

5 Overview of Patient Safety Regulations COMAR , Maryland Patient Safety Program Enacted in March, 2004 Requires mandatory hospital reporting of Level 1 adverse events (those that cause death or serious disability, defined as lasting seven days or still present on discharge). Requires disclosure to patient/family. Also requires submission of RCA within 60 days of reporting. Nearly 3000 adverse events reported since 3/

6 State of the State Nationwide decrease in hospital-acquired conditions (HACs) of 17% between 2010 and report by CMS showed Maryland had reduced potentially preventable readmissions by a higher percentage than any other State, and decreased MHACs by 26%. However; one person per week dies in a Maryland hospital of a preventable adverse event.

7 Average FY15 L1 Reports per Hospital by Bed Size FY13 FY14 FY >300 (n=11) (n=14) (n=17) <99 (n=22) 7

8 Level 1 Reports Past Four Years Vascular Access Suicides Restraint/seclusion injuries OR events FY15 FY14 FY13 FY12 Misdiagnosis Medication Errors Maternal/Child Healthcare-associated Infections HAPU Falls Delays in Treatment Assaults Airway Events Abuse/Sexual abuse

9 Age and Adverse Events Proportion of hospital admissions in Maryland with a level 1 safety event ( ) (n=607) as compared to the national average admission rate for a given age group (2012). 41% 28% 25% 25% 27% 15% 13% 12% 3% 8% 1% 4% <1 Year 1 to 17 Years Years Years Years 85+ Years % of hospital admissions in Md with Level 1 patient safety event % Hospital admission by age group according to AHRQ HCUP report

10 Age and Adverse Events, FY Airway Suicides Falls Delays HAPU Medication errors Surgical events

11 FY2015 Event Outcomes Airway Events Delays in Treatment All Medication Fatal PVS/Anoxic Loss of Function Transfer to Higher LOC Increased LOS Surgery Medical Treatment All Surgical HAPUs Falls

12 Surgical Adverse Events Wrongs Posting errors: Surgeon s office (a relative) posted wrong procedure and patient consented to posted procedure. Marking errors: Pt. had block on correct leg, then was flipped back to front 2 times before incision and wrong leg done. Cases involved laterality done in procedure areas not used to marking laterality. One vendor-related implantation of left knee prosthesis into right socket. RFBs Six patients with retained guide wires from CL insertion. Eight women with retained vaginal sponges, bulb syringes, etc. Post-op breast surgery with recurrent infections and non-healing wound. One year later, mammogram found retained sponge. Gyn surgeon doing second case realized first patient left OR with RFB in vagina. Removed in PACU. Two reports from Birthing Centers, where the family-friendly atmosphere encouraged the clearing away of bloody drapes and sponges before the final count. 12

13 Delays: Significant Contributing and Correlative Factors Language or sensory deficits 3 Failure to follow up on symptoms 8 Monitors 6 Hand-offs 6 Diagnostics 9 Blood transfusion 5 Consults 4 Assessments 4 ED care 4 13

14 Delays in Treatment Four days after PEG placement, confused patient pulled it out just enough to rupture stomach. Deteriorated over next two days without intensivist assessment and had a delayed surgical consult. Patient died the day after ex. lap. found abdomen full of tube feeding. Patient to ED with abdominal pain and constipation. Triaged but no VS done for >1.5 hrs because day ED tech angry with night tech so no report was exchanged. First B/P was below 50. RN did not believe this because patient was A&O, so MD was not notified. RN then unable to get a BP, and asked other nurses to try again without notifying MD. MD to bedside when patient vomited and arrested. Patient to ED following collision, broken ribs, abdominal bruising. Emergently intubated for 2 days following anaphylactic reaction. When extubated, c/o 10/10 abdominal pain. 50+ hour delay in diagnosing bowel perforation and other significant internal injuries. 14

15 More Delays Patient to ED with C/O abdominal pain. Had very high B/P. History of alcoholism so assumption was pancreatitis. Patient to Observation bed without cardiac monitoring. CT without contrast was done that evening but not read. RN called MD next day to report that CT had not been read, but no other action was taken. Patient arrested and died after 24 hours without treatment for B/P. Autopsy revealed ruptured AAA. Patient had been in same Obs unit 2 days prior with same symptoms. Also had no treatment of B/P during that admission. A patient was taken to surgery following a car accident to repair a compound fracture of his leg. The repair took several hours longer than normal due to the patient s heavily muscled physique. Lab work had been sent halfway through the surgery and returned very abnormal results. The surgeon and staff in the OR assumed that the abnormal results were an artifact of hemolysis but did not retest the patient. Throughout the eight hour surgery the patient had low blood pressure and low urine output. When the patient finally had a headto-toe assessment in the PACU, he was found to have compartment syndrome in the non-operative leg and rhabdomyolysis. Before the patient could be taken back to surgery, he suffered a cardiac arrest and could not be resuscitated.

16 Cognitive Biases in Delays Cognitive Bias Definition Example Availability Heuristic Anchoring heuristic (premature closure) Framing effects Blind obedience Diagnosis of current patient biased by previous experience. Relying on initial diagnostic impression. Ignoring disconfirming evidence. Decision-making biased by subtle cues and collateral information. Placing undue reliance on test results or expert opinion. An alcoholic was incorrectly treated for pancreatitis despite indications that patient had an aortic dissection. Extremely high B/P was ignored. Elevated intra-op potassium level dismissed as hemolyzed. A heroin addicted patient with abdominal pain was treated for withdrawal. Later found to have bowel perforation. Waiting for the blood bank to finish analyzing blood without questioning the extended delay.

17 Adverse Event no. 1 Patient had an invasive procedure performed by a surgeon not credentialed to do the procedure. Surgeon told OR team that if that procedure needed to be done, there was a credentialed surgeon standing by, but went ahead and did the procedure without help. Patient did not do well and required a return to OR on POD 5. When the ICU staff realized the original surgeon had also decided to do the repair, they voiced their concerns to the Chief of Surgery. The Chief told them to let this surgeon do the procedure. Patient transferred a few days later to a higher level of care for repair of an internal dehiscence of surgical site.

18 Adverse Event no. 1, continued Surgeon had posted the patient for a procedure that he never intended to do, then twice performed a procedure for which he was not credentialed. Circulating RN noted the discrepancy between the consent and the posting but did nothing. Case was referred for peer review nine months after event. RCA did not mention actions of Chief of Surgery. Hospital retrained nursing staff on the chain of command. Neither RCA nor action plan addressed the culture in OR or among the medical staff. 18

19 Adverse Event no. 2 OB patient got a dose of erythromycin and had sudden onset tachycardia, SOB, chest pain. RRT called and patient moved to telemetry unit. Couple hours later, another OB patient got a dose of erythromycin and had same reaction. Infusion stopped as soon as she became symptomatic and she quickly recovered. All erythromycin removed from patient use. Testing revealed epinephrine in the bags. 19

20 Adverse Event no. 2, continued Pharmacy tech who mixed meds had just finished orientation. Tech was used to making up epinephrine, insulin, and other emergency drugs. Since meds are stored alphabetically, the erythromycin was kept next to the epinephrine in the pharmacy. Techs are supposed to use the bar code system when making up admixtures but the computer was often down and in this case had been down for 2 days without anyone calling for repairs. The tech attached the vials to the bags for the pharmacist to check but the pharmacist was very busy with STAT meds and assumed the tech had used the barcode system so she only did a cursory check. RCA found problems with the way the HIT prints out labels. Their system printed by patient name and required a manual override to print by medication name, which would be safer. Hospital changed times that batch meds are reviewed by pharmacist to a less busy time. They upgraded their connectivity to reduce downtime, and changed review system so non-bar coded meds are rejected. 20

21 Root Causes for FY15 Events Training Supervision Policies Airway OR Events Delays Personnel Other Health IT Critical Thinking Complacency Communication Chain of Command Assessments

22 Associations between Events and Causation Delay Med. Error Airway OR Events Personnel Chain Of Command Critical Thinking Communication Training Policies Complacency Assessment Supervision Significant positive relationships between causative factors and adverse event types (OR, p<0.05)

23 Co-occurrence of Root Causes Supervision (4) Policy (2) Personnel (4) Chain Of Command (4) Training (5) Communication (5) Critical Thinking (6) Assessment (2) Four major clusters: 1) Yellow: Core Clinical Functions 2) Green: Clinical Team Work 3) Blue: Administrative Functions 4) Red: Attaining / Using Health Information Complacency (2) Pt Issues / HIT (2)

24 FY15 Corrective Actions Referral to Professional Board FDA Report Environmental Changes Discipline Change in Workload/Staffing Peer Review Equipment Mods Process Improvement Policy Change Education Data Tracking

25 Making Changes that Stick Aim the corrective actions at the correct failure point. Identify and fix latent issues. Consider hospital-wide generic solutions. Standardize and simplify wherever possible. Avoid reliance on memory. Consider cognitive biases. Share and learn from mistakes. Executive interest and support are key. 25

26 FY15 Summary Too many delays and surgical events. Culture change seems out of reach for many hospitals. Where are our systems of accountability? Why do we continue to discount the evidence of our monitoring equipment and our early warning systems just because the patient is talking and alert? Why do we continue to expect bedside nurses to keep all of the other disciplines in line? 26

27 New Patient Safety page on OHCQ web site: 27

28 Resources Guidance/Guidance/Manuals/Internet-Only- Manuals-IOMs- Items/CMS html?DLPage=1&DLSort=0& DLSortDir=ascending Go to the Appendices (pdf) and click on Appendix A for the Hospital A-Tags. Anne Jones RN, BSN, MA , anne.jones@maryland.gov 28