Effective Tools to Prevent and Manage Adverse Events Based on Office of Inspector General Adverse Events Report Diane C. Vaughn, RN, C-DONA/LTC; LNHA vaughndiane@hotmail.com
Objectives Upon completion Lesson 1 Overview of Adverse Events, the participant will be able to Articulate the 3 major categories of the Office of Inspector General Adverse Events Report in SNF s Understand the value and relationship of quality management in lowering the prevalence of adverse events Define the prevalence and contributing factors of adverse events Implement strategies to prevent, identify, and manage adverse events
Adverse events Congress Mandated Report Studied 653 Medicare Beneficiaries who transitioned from hospital to SNF PAC Found: 22% experienced an adverse event Over 50% returned to the hospital An additional 11% experienced a temporary harm event Cost of Care $208,000,000 in August of 2011 2,800,000,000 annualized for 2011 It is also noted that 70% of Medicare Beneficiaries will have a post acute care stay
Adverse events by clinical category Infection Events 26% Medication Events 37% Care Related Events 37% Better recognition of the problem is needed Improved documentation of the response Increased accountability for prevention
Adverse events definition Harm to a patient as a result of medical care This includes: Failure to provide needed care Medical errors in general More general substandard care e.g., infection from use of contaminated equipment Adverse events do not always involve errors, negligence, or poor quality of care Adverse events may be unavoidable
Adverse event: cascade event An event that included a series of multiple, related events. Excessive Anti-coagulation Polypharmacy creating fall risk Single drug causing multiple adverse events e.g. Anticholinergic class drugs
Adverse events: Medication related Medication-induced delirium or other change in mental status Excessive bleeding due to medication Fall or other trauma with injury secondary to effects of medication Constipation, obstipation, and ileus related to medication Other medication events
Adverse events resident care related Fall /trauma with injury related to resident care Exacerbations of preexisting conditions resulting from an omission of care Acute kidney injury or insufficiency secondary to fluid maintenance Fluid and other electrolyte disorders (e.g. inadequate management of fluid) Deep vein thrombosis (DVT), or pulmonary embolism (PE) related to resident monitoring Other resident care events
Adverse events: Infection related Aspiration pneumonia and other respiratory infections Surgical site infection (SSI) associated with wound care Urinary tract infection associated with catheter (CAUTI) Clostridium difficile infection Other infection events
Temporary harm events Medication 43% Resident Care 40% Infections 17%
Temporary harm: medication related Hypoglycemic episodes Fall or other trauma with injury r/t meds Medication-induced delirium or other change in mental status Thrush and other nonsurgical infections related to medication Allergic reactions to medications Other medication events
Temporary harm: resident care Pressure ulcers Fall or other trauma with injury associated with resident care Skin tear, abrasion, or breakdown Other resident care events
Temporary harm: infections CAUTI Surgical site infection (SI) associated with wound care Other infection events Early recognition is essential!
When do most adverse events occur? 1 st 48 hours after hospital transfer / admission to LTC (lack of a transition system) Transfers on Friday afternoons Lack of critical thinking by frontline nursing staff Lack of close communication among CNA s, nursing, IDT and physicians/aprn s
How is harm assessed? Did an event occur? What was the level of harm? Is this a case of omission or commission? Was the event preventable?
NCC MERP Index for Categorizing errors Harm does not reach patient A: Event had the capacity to cause error B: Event occurred but did not reach the patient C: Error reached the patient causing no patient harm D: Error reached the patient requiring monitoring to preclude harm or to confirm that it caused no harm
NCC MERP Index for Categorizing errors Harm reaches patient E: Error may have contributed to or resulted in temporary harm and required intervention F: Error may have contributed to or resulted in harm and required a prolonged facility stay G: Error contributed to or resulted in permanent patient harm H: Error occurred that required intervention to sustain the patient s life I: Error occurred that may have contributed to or resulted in a patient death
AD and temporary harm events by preventability rationales Treatment provided in a substandard way or not provided Resident s progress not adequately monitored Error r/t medical judgment, skill, or resident management Resident care plan was inadequate, incomplete, lacking clear description of condition Health status was not adequately assessed.
Adverse and temporary harm events by preventability rationales Appropriate treatment was provided in a substandard way Failed to use proper infection control procedures Failed to follow care plan for resident fall s management Staff capacity insufficient for treatment Floated staff from LTC to PAC without training
Adverse and temporary harm events by preventability rationales The resident s progress was not adequately monitored Anti-coagulation Management of blood glucose Labs not completed or reviewed as ordered Care plan / IDT not engaged with lack of progress towards goals
Adverse and temporary harm events by preventability rationales Necessary treatment was not provided Delay in care related to pharmacy delivery late Staffing related or communication of orders
Adverse and temporary harm events by preventability rationales Error was related to medical judgment, skill, or resident management Physicians sometimes fail to determine the right diagnosis contributing to cascade events Is the medical director active in reviewing negative outcomes?
Adverse and temporary harm events by preventability rationales Resident care plan was inadequate How engaged is the full IDT in the assessment and development of the care plan interventions? Is there a process to check on progress towards goals earlier than q 90 days? Do the front line staff know the interventions on the care plan for individual residents? Does the nurse ensure the CNA s assigned interventions were completed?
Adverse and temporary harm events by preventability rationales Care plan was incomplete or not sufficient in describing resident s condition MDS is a minimum assessment doesn t guide co-morbid condition management Creates silos of care via interdisciplinary roles
Adverse and temporary harm events by preventability rationales The resident s health status was not adequately assessed. What are your systems for educating staff to the complex conditions? Do you use on-line only or engage staff in simulation exercises to practice critical thinking?
QAPI Elements Design and Scope Governance and Leadership Feedback, Data Systems and Monitoring Performance Improvement Projects (PIP s) Systematic Analysis and Systemic Action CMS - QAPI: http://cms.gov/medicare/provider- Enrollment-and-Certification/QAPI/NHQAPI.html
Summary Adverse Events and Temporary Harm Event prevalence is too high CMS will be focusing on this most likely through the survey process Adverse events contribute to re-hospitalization rates Understanding the findings in the report and analyzing your care center through your quality management processes will assist you in identifying adverse events, determining prevention and management strategies and reduce the prevalence