Medication Errors, Patient Falls, and Pressure Ulcers: Improving Outcomes Over Time Patricia A. Patrician, PhD, RN, FAAN Colonel, US Army, Retired Associate Professor and Donna Brown Banton Endowed Professor University of Alabama at Birmingham Lori Loan, PhD, RNC Chief, Nursing Research Service Madigan Army Medical Center Tacoma, WA Mary McCarthy, PhD, RN Nurse Researcher Madigan Army Medical Center Tacoma, WA This research was funded by the TriService Nursing Research Program, #N03-P07. 1 Disclaimer This project was funded by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences (Grant #N03-P07). However, the information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. 2
National Databases ANA Nursing Indicators CALNOC 3 MilNOD Purposes Collect data to support evidence-based clinical and administrative decisions. Create a valid and reliable database consisting of nurse staffing and patient safety data collected at the shift. Provide a basis for comparison among similar military hospitals and CalNOC. Analyze relationships between staffing and outcomes. 4 Analyze outcomes over time.
MilNOD Participants Elmendorf Air Force Base Hospital, AK Malcolm Grow Medical Center, MD Wilford Hall Medical Center, TX National Naval Medical Center Bethesda, MD Naval Hospital Bremerton, WA Naval Hospital Oak Harbor, WA Naval Medical Center San Diego, CA Bassett Army Community Hospital, AK Brooke Army Medical Center, TX DeWitt Army Community Hospital, VA Madigan Army Medical Center, WA Walter Reed Army Medical Center, Wash DC Womack Army Medical Center, NC 5 MilNOD Sites * Madigan Army Medical Center, Tacoma, WA Walter Reed Army Medical Center, Washington DC * Army Navy Air Force
MilNOD Indicators National Quality Forum Indicators Nursing Structural Indicators RN, LPN, NA Active Duty, GS Civilian, Contract, Reservist Nursing care hours Nursing skill mix Nursing education & experience Explanatory Variables Patient acuity Patient turnover Contextual Features: Work environment Practice Environment Scale Nursing Work Index Patient Outcomes Pressure ulcer prevalence Restraint use prevalence Falls and falls with injury Medication administration errors Satisfaction with Care in general Nursing care Pain management Education Nurse Outcomes Job satisfaction Needlestick injuries 7 Data Acquisition & Dissemination Nurses enter daily staffing & census data into the unitlevel MilNOD database. Every month trained on-site staff collect fall, medication error & needlestick injury data from incident reports. Once each year patient & staff surveys are conducted by the MilNOD team. On-site trained staff conduct pressure ulcer & restraint use prevalence data on a semiannual basis. MilNOD team checks and improves data quality. MilNOD team prepares reports & investigates best practices. Reports are disseminated to hospitals quarterly. MilNOD team works with hospitals to understand & use reports. Hospital leaders use data to identify problems & evaluate solutions. Best practices, evidence-based practice policies, and effective solutions are shared across hospitals via conference calls and newsletters. 8
Key MilNOD Education and Technical Support Orientation sessions for new sites & refreshers for existing sites Open forum conference calls to discuss issues Access to project staff for questions & individualized coaching Email updates and quarterly newsletters Web-based based materials: Codebooks, data reports and graphs, tutorials, patient safety posters, and Powerpoint presentations Best practice managers disseminate policies and standards across sites and help sites use data to improve practice 9 Significance of MilNOD Shift level, prospective data collection Standardized data definitions Significant effort to establish reliability, validity, and usefulness of data Separate analysis for critical care, med-surg, step-down units Military data 10
Research question: Over time, have MilNOD facilities decreased adverse patient outcomes? 11 MilNOD Sample 13 hospitals 6 small = <50 beds 7 large = >100 beds 47 units had enough quarters of data to examine outcomes (adverse events) over time Study conducted from 2003 to 2006 12
Data Analyses: Repeated Measures ANOVA 13 Analysis Falls per 1,000 Bed Days 10 10 9 8 7 6 5 4 3 2 1 0 0 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr 3rd Qtr Baseline 04 2nd 04 Qtr 3rd 04 Qtr 04 4th Qtr 05 5th Qtr 05 6th Qtr 05 7th Qtr 05 8th Qtr 06 9th Qtr 06 10th 06 Qtr 1 2 16 16 47 47 37 37
Patient Outcomes Significantly Improved Medication Administration Error Rates by 50% (p=0.019).57 per 100 Bed Days.26 per 100 Bed Days (n=47 s) (n=45 s) (n=36 s) (n=34 s) (n=30 s) (n=25 s) (n=25 s) (n=24 s) (n=23 s) (n-23 s) 15 Patient Outcomes Significantly Improved Patient Fall Rates by 69% (p=0.028).33 per 100 Bed Days.10 per 100 Bed Days (n=47 s) (n=45 s) (n=36 s) (n=34 s) (n=30 s) (n=25 s) (n=25 s) (n=24 s) (n=23 s) (n-23 s) 16
Patient Outcomes Significantly Improved Patient Fall with Injury Rates by 30% (p=0.11).07 per 100 Bed Days.02 per 100 Bed Days (n=47 s) (n=45 s) (n=36 s) (n=34 s) (n=30 s) (n=25 s) (n=25 s) (n=24 s) (n=23 s) (n-23 s) 17 Patient Outcomes Significantly Improved Hospital Acquired Pressure Ulcer Prevalence by 62% (p=0.036) 30% 21.3% HAPU Prevalence Percent of Patients with HAPUs 20% 10% 8.1% HAPU Prevalence 0% Baseline 2nd Survey 3rd Survey 4th Survey n=20 s n=20 s n=20 s n=20 s Hospital Acquired Pressure Ulcer Prevalence (p=0.036) 18
Why does the MilNOD have an impact on outcomes? Implementing Database Processes Increases Evidence Based (EB) Practice Example: MilNOD Pressure Ulcer (PU) Practice Enhancements Before MilNOD After MilNOD Regular HAPU data 36% 100% collection EB PU risk assessment 27% 100% tool used PU prevalence study 36% 100% PU EB & current 25% 100% staging criteria used 19 Conclusion and Implications The MilNOD is an efficient, replicable, and sustainable initiative for inpatient care units. The database methodolgy appears to contribute to patient care improvements over time. MilNOD units significantly decreased adverse events over the study duration. Cost avoidance for falls and med errors $1,130,000/year Cost avoidance for pressure ulcers $450,000/year 20
Questions? Pat Patrician ppatrici@uab.edu 205-996-5211 21