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Maryland Association for
Healthcare Quality
Fall Conference
Anne Arundel Medical CenterAnnapolis, MD
October 29, 2009
Vivian Miller, BA, LHRM, CPHQ, CPHRM, FASHRM
Risk Management/Patient Safety Specialist
Center for Performance Sciences
Maryland’s Road to Patient Safety – Where Are We Now?
© MPSC, 2009
© MPSC, 2009
The Maryland Patient Safety Center became part of a unique approach to patient safety that was originally developed by the Maryland Health Care Commission (MHCC) in response to legislation passed by the Maryland General Assembly in 2001, which occurred almost immediately following Josie’s death.
Designated by the Maryland Legislature and the Maryland HealthCare Commission in 2004, our vision is to make Maryland’s healthcare the safest in the nation.
We want all Maryland hospitals tied for first place in the provision of safe, high quality care to our entire patient population.
© MPSC, 2009
The Maryland Patient Safety Center is a 501(c)3, non-profit organization, and as such, is governed by a voluntary Board of Directors comprised of Hospital Senior Executives, as well as representatives from Academia, MHA, the QIO, OHCQ, our patient population, and third party payors.
The Executive Director is William Minogue, MD, a retired family practitioner and former hospital CEO
The Director of Operations and Development is Inga Adams-Pizarro
© MPSC, 2009
Additionally, there is an MPSC employed Executive Assistant, and
A programmer, along with myself, who are contracted staff through another MHA subsidiary to provide services on behalf of MPSC.
© MPSC, 2009
The Maryland Patient Safety Center has since been now re-designated as the state’s Patient Safety Organization from January 1, 2009 to December 31, 2014
The Maryland Patient Safety Center has also been listed as a federal Patient Safety Organization for three years effective December 10, 2008 through December 9, 2011
© MPSC, 2009
The Maryland Patient Safety Center brings together health care providers to study the causes of unsafe practices and put practical improvements in place to improve the quality of care provided as well as to prevent medical errors.
This approach combines limited mandatory reporting of serious adverse events to the state health department with voluntary systems improvement activities coordinated by a statewide patient safety center.
© MPSC, 2009
To carry out its charge to improve quality of patient care and promote patient safety in Maryland, the Center focuses on the following four activities: Collaboratives Education Research Data Collection
© MPSC, 2009
Since July 2006, the Maryland Patient Safety Center has been collecting data after careful planning of how and what should be collected; and, what difference it can make to quality and safety of care
© MPSC, 2009
Today’s discussion is about the progress we have made, and how the data MPSC has collected over the last 4 years are being used by Maryland healthcare providers to their organization’s strategic patient safety initiatives.
It is also about analyzing key aspects of structures, processes, and outcomes of care that could have a direct impact on patient safety, as well as evaluating an organization’s progress toward a successful “culture of safety.”
© MPSC, 2009
MPSC’s Adverse Event Reporting System (AERS) collects data related to Adverse Events Near Misses RCA and FMEA Processes
Maryland Patient Safety Center Data
© MPSC, 2009
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10%
15%
20%
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Incident Type
Top 15 Incidents Reported by Volume, 2008
© MPSC, 2009
Top 15 Incidents Reported by Volume, 2008
Total Number of Incidents Reported = 7,977
Incident Type Count % of Total Incidents Reported Harm No Harm Don't Know Ratio Harm/No Harm
Medications 1639 20.55% 73 1081 485 0.07 1:15
Falls 1068 13.39% 247 647 174 0.38 1:3
Laboratory 883 11.07% 72 382 429 0.19 1:5
Provision of Care 859 10.77% 202 277 380 0.73 1:1
Injury (needle stick, etc.) 660 8.27% 484 76 100 6.37 6:1
Medical Records 622 7.80% 12 467 143 0.03 1:39
Unexpected Departure 385 4.83% 0 105 280 0.00 NA
Security 348 4.36% 37 224 87 0.17 1:6
Other 334 4.19% 66 118 150 0.56 1:2
Communication 299 3.75% 32 152 115 0.21 1:5
Drug 250 3.13% 85 138 27 0.62 1:2
Surgical 223 2.80% 24 82 117 0.29 1:3
Equipment 215 2.70% 42 106 67 0.40 1:3
Radiological 181 2.27% 13 68 100 0.19 1:5
Patient Feedback 176 2.21% 17 128 31 0.13 1:8
© MPSC, 2009
Summary of Incidents Reported by Volume, 2008
Medication errors accounted for 21% of total incidents reported 11% resulted in harm
Falls accounted for 16% 23% resulted in harm
Laboratory incidents accounted for 11% 8% resulted in harm
Provision of Care accounted for 11% of total incidents reported 24% resulted in harm
Injury accounted for 8% of total incidents reported (i.e., Abrasion/Burn/Bumps; Aspiration; Blisters Broken or Missing Teeth; Bruise; Choking; Laceration (w or w/o Stitches);
Needle Sticks; Self-inflicted Injury; Skin Tear; Struck by Object; Swelling/Edema)
© MPSC, 2009
Maryland Office of Healthcare Quality
Finding: Per the Office of Health Care Quality, for year 2008, Falls remain the most reported type of Level 1 Event that resulted in serious injury, illness and/or death. (More to come during the OHCQ Presentation)
© MPSC, 2009
Other patient characteristics are not reported to the OHCQ, but are
associated with high risk for falling.
incontinence age-related declines chronic disease, acute illness **medications (24.17% per MPSC data)
Prevalence and Morbidity, and Causes, Chapter 21-Falls, Douglas P. Kiel, MD, MPH
© MPSC, 2009
There is a clear relationship between falling and:
1.**Polypharmacy, (patients being on more than 4 medications for acute care, on more than 9 for long term care)
2. Postural control, i.e., environment, changing positions, increase or decrease in normal activities
3. Other mediating factors, i.e., risk taking behaviors underlying mobility level such as disregarding fall prevention education by staff
© MPSC, 2009
This data were used to: Assist in the establishment of a Falls Work Group Develop and implement Roadmaps and Provide
Tools designed to assist healthcare facilities across the continuum of care reduce the frequency and severity of falls
Data and other information was shared with the MEDSAFE Team for presentation at the 2008 Annual MEDSAFE Conference
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
All levels of analysis indicate that MPSC participants’ greatest opportunities for improvement are within the following key elements Patient Information Staff Competency and Education Quality Process and Risk Management
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
Greatest opportunities for improvement within the following core characteristics: Essential patient information is obtained, readily
available in useful form, and considered when prescribing, dispensing, and administering medications
Essential drug information is readily available in useful form and considered when ordering, dispensing, and administering medications
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
Practitioners receive sufficient orientation to medication use and undergo baseline and annual competency evaluations of knowledge and skills related to safe medication practices
Practitioners involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
A non-punitive, system-based approach to error reduction is in place and supported by management, senior administration and the Board of Trustees/Directors
Simple redundancies that support a system of independent double checks or an automated verification process are used for vulnerable parts of the medication system to detect and correct serious errors before they reach patients
© MPSC, 2009
Summary of 2008 Education Session
Don’t Fall on Your Meds! (September 25, 2008) Medications’ Influence on the Risk of Falls – What the
Data Suggests National Perspectives on Fall Reduction Efforts Medications that Put Hospitalized Patients at Risk for
Falling Patient Falls Case Review – Diuretics and Sleep
Medications Falls and Medication Safety – Systems and Processes Discussions and Lessons Learned
© MPSC, 2009
So, what does the data show for 2009 to date?
© MPSC, 2009
© MPSC, 2009
Incident Type Count% of Reports Harm
No Harm
Do not Know
Ratio Harm/No Harm
Near Miss
Laboratory 730 15.26 9 236 485 0.04 52Medications 695 14.53 8 522 165 0.02 143Falls 607 12.69 204 321 82 0.64 17Provision of Care 547 11.43 72 202 273 0.36 28Injury 436 9.11 346 33 57 10.48 0Medical Records 348 7.27 0 280 68 0 41Security 304 6.35 15 203 86 0.07 7Communication 226 4.72 8 126 92 0.06 22Surgical 198 4.14 22 77 99 0.29 6Unexpected Departure from Facility 197 4.12 0 51 146 0 0Radiological 143 2.99 9 46 88 0.2 6Patient Identifier 132 2.76 0 94 38 0 24Drug 101 2.11 14 57 30 0.25 0Patient Feedback 95 1.99 6 73 16 0.08 0Infection 94 1.96 10 13 71 0.77 0
Incidents Reported by Volume through September 2009Total number of incidents reported 4784
© MPSC, 2009
Summary of Incidents Reported by Volume, through September 2009
Laboratory errors accounted for 15% of total incidents reported, up 4% from 2008) 1% resulted in harm
Medication errors accounted for 14% of total incidents reported (down by almost 5% from 2008) 1% resulted in harm (down 22% from 2008)
Falls incidents accounted for 13% of total incidents reported (up 2% from 2008) 34% resulted in harm
Provision of Care accounted for 11% of total incidents reported 13% resulted in harm, (down 11% from 2008)
Injury accounted for 9% of total incidents reported, up 1% from 2008) (i.e., Abrasion/Burn/Bumps; Aspiration; Blisters Broken or Missing Teeth; Bruise; Choking; Laceration (w or w/o
Stitches); Needle Sticks; Self-inflicted Injury; Skin Tear; Struck by Object; Swelling/Edema)
© MPSC, 2009
Future Considerations for MPSC based on Data
Drill down Laboratory Errors, determine possible contributing factors, i.e., improper collection, specimen mislabeled, patient identification, etc.
Drill down Provision of Care Errors, determine specific type of error, i.e., delay in treatment, delay in diagnosis, delay in response, etc., particularly in light of recent article published in JAMA. 2009;301(10):1060-1062, entitled “Diagnostic Errors—The Next Frontier for Patient Safety”, by David E. Newman-Toker, MD, PhD and Peter J. Pronovost, MD, PhD
© MPSC, 2009
According to the article, “....although the science of error measurement is underdeveloped, diagnostic errors are an important source of preventable harm.”
© MPSC, 2009
Next Steps for The Maryland Patient Safety Center (MPSC)
Continue to develop and deploy upgrades and improvements to the current adverse event reporting system so that data collected accurately reflects what types of events are actually taking place in Maryland hospitals
Provide a routine, comparative data review and analysis for each participating institution, including near miss data
Provide an annual report on identified trends within each participating institution, also including comparisons to other regional and national data
Provide an annual assessment of the status of patient safety efforts in participating institutions to show how MPSC and the Adverse Event Reporting System has contributed toward making Maryland’s Healthcare “the Safest in the Nation”.
© MPSC, 2009
Questions?
© MPSC, 2009
For more information, contact:
(410) 379-6200