We Harm Patients Too: Ambulatory Patient Safety James Park, MD Associate Medical Director Primary & Urgent Care Jeri Craine, RN, MN Health Promotions Program Manager UW Medicine Valley Medical Center Clinic Network Ambulatory Patient Safety Objectives Recognize the importance of ambulatory patient safety as a priority in their organization Develop an ambulatory patient safety program within their organization Utilize a multidisciplinary ambulatory patient safety committee to drive improvement in their organization Discuss the differences between inpatient and ambulatory patient safety and identify ambulatory-specific patient safety issues 2 1
3 To Err is Human 44,000-88,000 deaths/year 8 th leading cause of death 4 2
Crossing the Quality Chasm SEPTEE Safe Effective Patient Centered Timely Efficient Equitable 5 Quality vs. Safety Cancer screening Diabetic Care Depression Care Recall Effectiveness Appropriate Antibiotic usage Appropriate imaging for low back pain Procedure verification Specimen Labelling Medication administration Medication prescriptions Result notification Care documentation 6 3
Run to Space 7 4
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11 Ambulatory Patient Safety 52% of malpractice claims paid out for events in ambulatory setting 2/3 involve major injury or death Very little data on ambulatory patient safety Researchers work in inpatient setting Inpatient errors are commission, outpatient omission Patients role is more complex 12 6
Ambulatory Patient Safety 1) Collect basic data on how many patients are harmed in ambulatory settings 2) Set an early, achievable goal 3) Engage patients and their families as equal members of ambulatory patient safety teams 4) Link ambulatory patient safety to inpatient safety 5) Create demonstration projects 13 Culture of Safety Survey According to the Agency for Healthcare Research & Quality (AHRQ), the definition of safety culture is: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives. How to Measure Ambulatory Culture of Safety : In 2009, AHRQ developed a Culture of Safety Survey for Medical Offices. 7
Document contains information protected by peer review/quality assurance confidentiality under RCW 4.24.250 and/or RCW 70.41.200. Information may also be protected by attorney-client privilege and/or work product doctrine. 15 Culture of Safety Survey 16 Document contains information protected by peer review/quality assurance confidentiality under RCW 4.24.250 and/or RCW 70.41.200. Information may also be protected by attorney-client privilege and/or work product doctrine. 8
AHRQ 10 Key Areas 17 Document contains information protected by peer review/quality assurance confidentiality under RCW 4.24.250 and/or RCW 70.41.200. Information may also be protected by attorney-client privilege and/or work product doctrine. Event Reporting Can t improve it if you can t measure it Barriers Reporting exists How to report What to report When to report What happens when I report? Will I get someone in trouble? Will I get in trouble? 18 9
Just Culture Four Categories of error Human error I gave the wrong vaccine because I misread a label Negligent behavior I gave the wrong vaccine because I didn t pay attention at the staff meeting Reckless behavior I didn t bother to look at the orders and gave the wrong vaccine Knowing violations I knew the process and chose to disregard it and ended up giving the wrong vaccine. 19 Just Culture Different Responses to different errors Console the error I m sorry that you were involved in this error. How are you feeling? Counsel the at-risk To keep our patients safe, it is important to learn and follow the processes that we have put in place. Please let me know if you have any difficulty with maintaining these processes Punish the reckless This is a written warning 20 10
Just Culture 21 Error Reporting Year Number of Safety Error Reports 2011 147 2012 442 2013 474 Why the Numbers are Important: 1. Awareness of Importance of Reporting 2. Ability to Trend Errors 3. Able to Design Interventions to Trends 22 11
Guidelines for Reporting Type of Report When to Enter a Report Safety & Risk Reports: Patient or Visitor Safety Events 2 working days Timeline for Reviewing a New Report After the manager receives notice of the event, the report is reviewed within 2 working days. Timeline for Investigation & Completion of Report The investigation is to be completed within 14 days. (If greater than 14 days is needed, consult with the Patient Safety Officer) Feedback Reports: Patient Complaints & Grievances 2 working days After the manager receives notice of the event, the report is to be reviewed within 2 working days. * Grievances: The investigation is to be completed within 14 days. (If greater than 14 days is needed, notify & consult with Risk Management). Complaints: The investigation should be completed and closed within 14 days. 23 2014 24 12
25 Identification of Trends Labeling No label Labels not sticking Incorrect Label Vaccines Td, Tdap, DTaP Not following vaccine schedule (too early, too late) Medications SALAD Sound Alike Look Alike Drugs Epic Conflicting Sig documentation 26 13
Labeling 27 Labeling https://youtube.googleapis.com/v/cg5imhh-tyk 28 14
Vaccine Errors Medication administration error Multiple tracking methods Multiple processes Standards not consistent across organization Harm is debatable 29 Vaccine Error Analysis 30 15
Vaccine Error Analysis 31 Document contains information protected by peer review/quality assurance confidentiality under RCW 4.24.250 and/or RCW 70.41.200. Information may also be protected by attorney-client privilege and/or work product doctrine. Medication Safety Pharmacy involvement is key Medication administration Vaccines Medication storage Samples Prescription writing Templates on EHR Dosage errors Pediatric dosing Linking diagnosis with drugs Oncology drugs 32 16
Medication Safety Document contains information protected by peer review/quality assurance confidentiality under RCW 4.24.250 and/or RCW 70.41.200. Information may also be protected by attorney-client privilege and/or work product doctrine. 34 17
35 Problems Not all clinics engaged in process Reporting not as robust as expected Lack of clarity around expectations for investigation turnaround time. Just culture still not clear across network 36 18
Solutions Committee reorganization Member from each clinic Multidisciplinary: Pharmacy, Patient safety officer, Risk Management, Lab, Operations Event follow up standards Re-emphasis on reporting through committee members Continued discussion regarding Just Culture 38 19
Timeline May 2011 Oct 2011 Dec 2011 Apr 2012 First Patient Safety Committee Meeting Just Culture Network Level Safety Event Reporting Developed Received State of Washington approval for official Coordinated Quality Improvement Program for the Clinic Network Nov 2012 Sept 2013 Oct 2014 Jan 2014 Clinic Level Reporting Developed Safety Committee updated structure to include representation from each clinic Event Mgmt Lag Reports Developed Provider Reports included in Coaching Program Established monthly review with Clinic Administration Reporting incorporated into Director monthly rounding 39 Lessons Learned Ambulatory Patient Safety needs its own space Reporting is step one Regular assessment of culture is beneficial Multidisciplinary team helps with analysis, problem solving and implementation Progress is slow Reversals are common Champions are needed 40 20
QUESTIONS? 42 21