Patient safety Graham Ramsay U.K. Main Themes Patient safety is the foundation for quality Safety improvement May require better structures, resources Always requires better processes Standardising process improves safety Improving processes can save money Process improvement drives outcome improvement But auditing process is time consuming Therefore Monitor only key processes If outcome parameters change examine all processes Main Themes (2) EBM- do what we should do. Do we? Creating a learning organisation Blame free reporting Near incident reporting Stoplight system Conclusions Safe Care Of Patients? Questions to ask Three questions: 1. Do you know of any mistakes in patient care in the last 3 months? 2. Do you have complete confidence in your hospital to provide safe care for someone you love? 3. If your hospital was an aircraft, would you fly in it? Medical Error in hospital practice Medical Admissions to Intensive Care NCEPOD report An Acute Problem? May 12 th 5 http://www.ncepod.org.uk/5report/ncepod_report_5.pdf n AEs Negligent Fatal New York 1 3121 3.7% 27.6% 13.6% Col/Utah 2 15 2.9% 3% 6.6% Australia 3 1 16.6% 51% 4.9% London 4 114 1.8% 48% 8% ICU, France 124 16% -.6% ICU, Israel 5-1.7/pt/d 2/day - 1. NEJM 1991; 324: 37-6. 2. Medical Care ; 38: 261-71 3. Med J Aust 1995; 163:458 471. 4. BMJ 1; 322:517-519 5. Crit Care Med 1995;23:294-3 www.metconference.com 1
NCEPOD findings Case note review of 469 of 56 deaths 1:1 cases inadequate initial history & clerking 42% suboptimal management after hospital admission 61% not seen by consultant physician in first 24 hrs ( cases evaluable; 28 stayed > 24 hrs in the ward; 11/28 (39%) seen by consultant physician within 24 hrs) 11-16% deficiencies in resuscitation and physiological management 57% consultant physician unaware of ICU referral 24% no ICU consultant involvement within 12 hrs of ICU admission 58 patients admitted to ICU, but classified by assessors as unsuitable, because likely to die NCEPOD: areas for improvement Pre-ICU care: acute care physicians Patient observation and review Training, supervision & support Outreach ICU referral, assessment, admission and review processes Record keeping Pathology services, M&M The view of the media?... Lessons from NCEPOD Process control Identifying system weaknesses Error-proofing: care bundles, IT Team-based care Communication & leadership Bridging gaps Media Education & training Focus on integrated acute care Changing Health Systems: Commonalities the common challenge of the acutely ill patient Cost containment Use of for-profit services Mobility of workforce Working hours Demographic changes Acute hospital beds Throughput, LOS Emergency admissions Proportion > 65 yrs Clinical error the new epidemic Changing perceptions of health care Views of Physicians & the Public on Medical Errors Blendon RJ et al. NEJM 2; 347: 1933-19 Questionnaire surveys of 831 practicing physicians Telephone interviews with 17 members of the public 35% physicians, 42% members of the public reported errors in their own or a family member's care Public s views about methods for improvement: Physicians to spend more time with patients (78%) Teamworking & communication issues (67%) Hospital systems for preventing errors (74%) Better training of health professionals (73%) Intensivist-delivered care in ICUs (73%) Suspension of licenses of health professionals (5%) Improving Methodological issues Taxonomy of error Risk assessment Opportunity for error Measurement: outcome or process Complexity & process control Interventions Translation into clinical practice www.metconference.com 2
Adverse events: the tip of the iceberg Heinrich HW (1941). Industrial accident prevention: A scientific approach. New York and London Unsafe systems: penetration of latent errors Reason JT, Human Error, Camb Univ Press, 199 1 Major AE 29 Minor AE Root cause analysis 3 Near miss Types of Adverse Events Frontline clinicians: Managing risk at the sharp end Sharp End Patient / Health Care Provider / Team / Task and Environmental Factors Examples: Medication AEs, Nosocomial Infections Sharp End: Immediate Cause(s) Contributing Factors Blunt End: Blunt End Examples: Management/ Root Underlying Cause(s) Communications Organizational/ Cause(s) Culture Regulatory Physical Factors Environment Policies / Procedures Adapted from the NHS Report Doing Less Harm, 1 14 Interpreting risk & reliability How (Un)reliable is Healthcare? Reliability = frequency with which actions produce intended results 1-1 means that 1 to 9 times out of 1 the intended actions or results fail or are defective. Eg: 8% compliance with giving appropriate DVT prophylaxis (2 omissions in every 1 patients) 1-2 means that 1 to 9 times out of 1 the intended action or results fail or are defective. Eg: 96% compliance with giving appropriate DVT prophylaxis (4 omissions in every 1 patients) How do we measure up? www.metconference.com 3
How (un)reliable are Health Care Processes? (Un)Reliability 1-1 1-2 1-3 Outcome/Process Beta blockers & ASA in Acute MI HbA1c tested at least 3 times every 2 yrs Mammograms, Immunisations, DVT proph Serious adverse events in hospital Deaths in high risk surgery Neonatal mortality General surgery deaths 1-4 Deaths in routine anesthesia 1-5 Blood Banks 1-6? Aviation industry (civilian, not military) Surviving Sepsis Campaign Do we do what we should do? McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New Engl J Med 3;348. Implementing best practice (Sepsis) Care Bundles Surviving Sepsis Campaign (SSC) guidelines for management of severe sepsis and septic shock Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM and the SSC Management Guidelines Committee Crit Care Med 4;32:858-873 Intensive Care Med 4;3:536-555 available online at: www.survivingsepsis.org www.esicm.org www.sccm.org www.sepsisforum.com 1. Synergism between effective treatments 2. Build teamwork and accomplish more than individual elements alone 3. Improves human factors and creates high reliability 4. Components must be achievable in clinically relevant time and location 5. Components not currently being implemented effectively Sepsis Resuscitation Bundle (Start immediately, complete within 6 hours) Serum lactate measured. Blood cultures obtained before antibiotic administration. From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non- ED ICU admissions.. In the event of hypotension: Initial minimum of ml/kg of crystalloid (or colloid equivalent). Vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. If persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate > 4 mmol/l (36 mg/dl): Achieve a central venous pressure (CVP) of > 8 mm Hg. Achieve central venous oxygen saturation (ScvO2) of > 7%.* Sepsis Management Bundle (To be started immediately and completed within 24hours) Steroids administered for persistent septic shock. Drotrecogin alfa (apc) administration in accordance with hospital guidelines. Glucose control maintained > lower limit of normal, but < 1 mg/dl. For mechanically ventilated patients, plateau pressures maintained < 3 cm H 2 O. * Achieving a mixed venous oxygen saturation (SvO2) of 65% an acceptable alternative. www.metconference.com 4
ARDSNet Low Tidal Volume Study: Mortality Prior to Discharge Mortality (%) 5 3 1 P=.7 ARDSNet. N Engl J Med ;342:131-8. 6 ml/kg 12 ml/kg Publication of Study Results Has No Effect on Practice ALI/ARDS Patients Receiving Lung-Protective Ventilation (%) P=.11 P=.2 Day of ALI/ARDS Rubenfeld GD, et al. Am J Respir Crit Care Med 1;163:A295. Adhere to Best Practice? SSC Campaign Initial Results: Reporting the Gap Between Perception and Practice % 1 8 6 Interview 92% Do you use lung protective strategy In ventilating acute lung injury patients? What We Think We Do Vs. What We Actually Do The Gap between Perception and Practice of Sepsis Therapy. FM Brunkhorst et al. for the German Competence Network Sepsis (SepNet). Submitted % 1 Interview 92% Adhere to Best Practice? Supportive and adjunctive therapies Results of the German Prevalence Study 1 92 Interview Audit 92 95 8 6 Audit 4% Results of Non-Scripted Care Processes. The Gap between Perception and Practice of Sepsis Therapy. FM Brunkhorst et al. for the German Competence Network Sepsis (SepNet). Submitted % 8 6 Low tidal ventilation 4 67 9 Glycaemic control 46 18 ScvO 2 1 1 79 31 23 APC Hydrocortisone septic shock severe sepsis 67 Low dose Dopamine non-use Antithrombin non-use 45 www.metconference.com 5
Opportunity for error Complexity & process control 7-1 data items recorded / hr Quality & safety: which do you control? The right resources used to deliver the Right care to the Right patients at the Right time to achieve the Right outcomes at an Appropriate social cost Structures Processes Outcomes PERFORMANCE Interpreting outcome data requires an understanding of care processes Processes of care are easier to measure and easier to improve Process audit of safety & quality is more empowering than outcome audit but is it more efficient? Summary Standardising process can improve safety and improve efficiency Process control throughout the patient journey is a necessary precondition for safety improvements Auditing process is time consuming Necessary during implementation Thereafter focus on outcome unless it changes Intermittent process checks Creating a learning organisation Role of blame free near miss reporting www.metconference.com 6