February 09, 2010, MGH, Swaziland Practical Approaches to development of patient safety information systemsChien-Tsai Liu, Professor Graduate Institute of Biomedical Informatics, Taipei Medical University The Conference on Patient Safety & Integrated Health Records

Patient safety definitions Narrowly: the issues specifically related to adverse events and their prevention

Broadly: any aspect of healthcare and health services that may lead to patient injury, and any interventions, including clinical, organisational and policy changes that aim to reduce injuryPatient safety is now one of the most important issues in healthcare internationally through the initiative World Alliance for Patient Safety led by the World Health Organisation (Oct. 2004 )

Medical ErrorsAdverse EventsNo harm eventsNear MissesPreventableeventsSentinel EventsNegligenceA Venn diagram of Patient safety definitions http://www.tjcha.org.tw/

Deaths associated with medical errors

5 elements for improving Patient safety A just or fair culture that encourages a reporting and questioning culture that is complemented by systems for reporting and analysing incidents both locally and nationally. A good in depth analysis process to establish root causes for selected individual incidents and aggregate incident reviews which enables learning. A process to ensure that actions are implemented, and corresponding improvements in patient safety and quality of care can be demonstrated. Effective processes for sharing information at various levels - nationally, organisationally and clinically - for learning and improvement. A redefinition of both punitive and non-punitive compensation systems in the healthcare environment, and an assessment of their impact on the patient safety culture and its achievements.

Major causes of medical errors & adverse events

Major causes of medical errors & adverse events Incomplete or missing informationMany adverse drug events could be avoided if healthcare providers had more complete information about which drugs their patients are taking and whyLack access to patients complete medical history. Organizational factorsDeficiencies in system design, organization and operation, including an organizations strategy, its quality management tools, and its capacity to learn and adapt

Main strategies for preventing medical errors and adverse events using ITTools to improve communicationMaking knowledge more readily accessibleAssisting with calculationsPerforming checks in real timeAssisting with systemic checking & monitoringProviding decision supportBates and Gawande, NEJM 2003

IT in healthcare applications: a reviewDecision Support SystemsComputerized Physician Order EntryAdverse event systems & alert systemsElectronic Medical Record (EMR)Incident reporting systems ICT systems can lead to considerable benefits in patient safety only if they are user-friendly and fully integrated with other relevant systems.

HAI surveillance systems: an example Hospital acquired infection (HAI) surveillance is a systematic, ongoing data collection, analysis and reporting process that quantitatively monitors temporal trends in the occurrence and distribution of susceptibility and resistance to antimicrobial agents, and provides information useful as a guide to medical practice, including therapeutics and disease control activities. . A HAI surveillance system features: Multiple systems involvedIntegrated work & information flows;Decision support; Monitoring & Alerts; Reporting

UTI Risk factors extracted from EMRsLIS : Laboratory information system; IMS: Inpatient management information System PMS: Medication management information system; CPOE: computerized provider order entry

Risk factorsDescriptionSources fromfeverfever (body temperature >38)CPOE + IMSUrine/blood culture orderUrine/blood culture ordersCPOE + LISUrine/blood culture resultpositive urine/blood bacterial resultsLISurine routine examinationpyuria (urine specimen 10 white blood cell [WBC]/mm or 3 WBC/high power field of unspun urine)LISantibioticoral and injection antibioticsCPOE+ MMSinvasive devicesindwelling urinary catheter, cystoscopy, PCN, double J, cystofix IMS

Other EMRsInterconnected secure networksMsg deliveryData collection & integration engineHAI surveillance databaseAnalysis, visualization & presentationAlerts & reporting management Early detection of infected cases & clusters (DSS)RIS(Radiology images reports)LIS(Culture orders & results)IMS(patient admission data )CPOE(diagnosis & orders)NRS(care plan &drug administration) The framework of HAI surveillance system

Integrated patient profiles based on the CDC guidelinesDashboard for summary of patients infection informationRefresh patients informationSelection of risk predictorsRed: positive/yes; green: negative/no

Click a specific patient to view his detailed admission data

Decision support: Algorithms for detection of suspected HAI casesDiscrimination functions demonstrate high sensitivity ( 99.25%) & Specificity ( 94.92 %)

the confirmed cases can be exported to the excel files for further analysis

The confirmed cases can be linked to CDCs reporting system.

SummaryIT systems in healthcare applications have shown the effectiveness in reducing the number of advent events, and improving practitioner performance.The systems also could introduce or facilitate new types of errors (information errors and human-machine interface flaws)Evidence-based evaluation methods for evaluating such safe systems are critical.

Summary (2)Evidence-based evaluation methods for evaluating such safe systems are critical.Phase 1: a systematic review of the health informatics literature involving technology-facilitated or technology-induced error. Phase 2: reviewing the literature and generating a comprehensive heuristics that could be used to evaluate an HIS for technology-induced errors.Phase 3: conducting evaluation of the system using evidence-based heuristics Healthcare quarterly Vol. 12 Special issue 49-54: Ensuring the safety of health information systems: using heuristics for patient safety

Thank you !!Chien-Tsai Liu TEL: +886-2-27361661 # 3342Email: ctliu@tmu.edu.tw

patient safety: errorbiasaccident( 2005 8 , www.tjcha.org.tw)

To Err Is Human26 (2000) and Crossing the Quality Chasm27 (2001), patient safety issues have received considerable attention internationally.The 1st report includes an estimate that systems failures in healthcare delivery (i.e. poorly designed or broken care processes) are responsible for between 44,000 and 90,000 deaths in the US each year. The 2nd report reveals a wide chasm (opening) between the quality of care that the US health system should be capable of delivering, given the astounding advances in medical science and technology in the last 50 years of the twentieth century, and the quality of care that most Americans actually receive Medical errors are the failure of a planned action to be completed as intended, or use of the wrong plan to achieve an aimThe problem of patient safety definition: If a medical error approach to patient safety is chosen, patient safety incidents are much more common. If however, an adverse event approach is chosen, the numbers are more likely to be smaller.

the US Commission on Systemic Interoperability points out that medical errors are killing more people each year than breast cancer, AIDS, or motor vehicle accidents altogether. the US Institute of Medicine estimated that systems failures in healthcare delivery were responsible for some 44,000 to 90,000 deaths each year

Drug: Adverse events in >1 in 10 pts ; 1/3 of these are serious ; In 8% of these cases, it lead to the patients death (Sir George, BMJ March 2002)Around 50 per cent of these patient safety incidents could be avoided, if only lessons from previous incidents were taken into account.A small study in the US found that around 25 per cent of out-patients experience an adverse drug event and that, in many instances, these were preventable or ameliorablepatient safety: errorbiasaccidentmedical adverse event: medical negligence: near miss: no harm event: preventable avoidable adverse event:

sentinel event) :

the US Commission on Systemic Interoperability points out that medical errors are killing more people each year than breast cancer, AIDS, or motor vehicle accidents altogether. the US Institute of Medicine estimated that systems failures in healthcare delivery were responsible for some 44,000 to 90,000 deaths each year

Less than one death per 100 000 encounters: Nuclear power, European railroads, Scheduled airlinesOne death in less than 100 000 but more than 1000 encounters: Driving, Chemical manufacturingMore than one death per 1000 encounters: Bungee jumping, Mountain climbing, Health care

The five elements of patient safety that most developed countries identify in their strategies for improving patient safety are :A number of developments in the health systems currently operating in European Member States, such as increased workload, significantly fewer care-givers, long work times, lower productivity and increased frustration, are leading to more and more medical errors. Th e causes of errors appear to be more dependent on the medical system and organisation then on clinical skills, Nanotechnology and wireless technology were named as key technology drivers that are able to help address these system-related errors.

the major causes of adverse events: the role of incomplete or missing information (particularly in medication-related adverse events), and According to the US Institute of Medicine, over half a million people are injured each year because of adverse drug events. Many of these could be avoided if healthcare providers had more complete information about which drugs their patients are taking and whyOut-of-hour pharmacies, the report notes, lack access to patients complete medical history.Organisational factorsdeficiencies in system design, organisation and operation, rather than on errors made by individuals,. Including an organisations strategy, its quality management tools, and its capacity to learn and adapt

The Institute of Medicine study (2000) suggests that several ICT possibilities exist in order to reduce the adverse drug event rate. In a hospital setting, these solutions include Computerised Physician (Professional) Order Entry, Decision Support Systems, and bar coding applications. In particular, electronic prescribing and monitoring for errors in all care settings is seen as essential. In addition to these technical components, improved provider-patient communication is a key component. Bar coding medications is considered a very effective measure Standard treatment guidelines finds the highest support among respondents high levels of support are found for the computerised ordering of medications and electronic medical records.

LIS : Laboratory information system; IMS: Inpatient management information System MMS: Pharmacy management information system; CPOE: computerized provider order entry

The surveillance system can automatically perform data collection, filtering processing and analysis, it can provide more complete electronic information based on the CDCs guideline.Four functions: (1) view all inpatients; (2) view suspect cases only; (3) view confirmed cases only; and (4) reporting to CDC

We designed different algorithms for detection of suspected HAI cases so that the workloads of infection control professionals can be reduced while increasing the surveillance sensitivity.

DF UTIs = -12.519 + 4.141 () + 2.209 () + 0.655 () + 6.646() + 2.282 () + 2.050 () -2.349 () +15.140 ()

DF not UTIs = -1.438 + 0.536() + 2.161() + 0.282() -0.310() + 0.514() + 0.690() -0.083() -0.242()

While health IT systems are expected to significantly reduce medication errors, recent studies have found that information fragmentation (i.e. not having all pertinent information on the same screen) in health IT systems can actually facilitate errors

CPOE systems are claimed to significantly reduce medication-prescribing errors. Our data indicate that that is often a false hope, says sociologist Ross Koppel, PhD, of the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine. Good computerized physician order entry systems are, indeed, very helpful and hold great promise; but, as currently configured, there are at least two dozen ways in which CPOE systems significantly, frequently, and commonly facilitate errors and some of those errors can be deadly.

After identifying 22 ways in which medication errors were facilitated by the CPOE system analyzed, Koppel and his research team grouped error types into two main categories: information errors; and human-machine interface flaws. Information errors, explains Koppel, result from fragmentation of data and information, or when there is a failure to fully integrate a hospitals multiple computer and information systems. Examples of these errors are when a physician orders the wrong dose of a drug because the CPOE system displays pharmacy warehouse information that is misinterpreted by the physician as clinical-dosage guidelines or when warnings about antibiotics are placed in the paper chart and not seen by physicians who are using only the computerized system. Human-machine interface flaws reflect machine rules that do not correspond to work organization or usual behaviors. For example, within the CPOE system studied, up to 20 screens might be needed to view the totality of just one patients medications thereby increasing the risk of selecting a wrong medication. To be effective, a CPOE system must articulate well with the work-flow within the organization, emphasizes Koppel. Phase one consisted of a systematic review of the health informatics literature involving technology-facilitated or technology-induced error. Phase two involved reviewing the literature and generating a comprehensive list of 38 heuristics that could be used to evaluate an HIS for technology-induced errors. Lastly, phase three involved conducting a heuristic evaluation of the VA CPRS system using evidence-based heuristics Healthcare quarterly (Toronto, Ont.) Volume: 12 Spec 49-54 Health information systems (HISs) are typically seen as a mechanism for reducing medical errors. However, there is evidence to suggest that technology can facilitate or induce medical errors. Therefore, it is crucial that we fully test systems prior to their implementation in real-world settings. Phase one consisted of a systematic review of the health informatics literature involving technology-facilitated or technology-induced error. Phase two involved reviewing the literature and generating a comprehensive list of 38 heuristics that could be used to evaluate an HIS for technology-induced errors. Lastly, phase three involved conducting a heuristic evaluation of the VA CPRS system using evidence-based heuristics