musolino bozza presentazione dipo 2012...benchmarking 2 feed back (region) monitor sentinel event 3...
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Dott. Maurizio Musolino ASL Roma B
Iatromics project
Clinical Risk Management Keywords
Dinamic and predictive approach, Health Service complexity, Clinical Risk assessment
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Iatromics project
!! Population (Italy) 60 x 106 (age: 0-14 = 14%; >65 years = 20%) !! Asl Companies 180 !! Population (mean value per Asl) 331.218 !! Hospitals managed by Asl 470 !! Hospital Company 97 !! IRCCS 55 !! University Hospitals 10 !! Private Hospitals 629 !! Hospital occupancy 270.000 !! Hospital admissions 8.200.636 !! % PIL ! 10 %
The numbers of Health Service complexity
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Iatromics project
A system designed to protect the organization, its employees patients and visitors from injury and loss of tangible and intangible assets
What is Clinical Risk Management?
Risk is a natural part of all healthcare. There is always the potential that an unwanted or unexpected outcome will occur whenever any
action is taken. Clinical risk management is therefore essential for improving
patient safety, and all practices are expected to undertake it as part of their clinical governance procedures.
system designed to designed to , its employees patients , its employees patients
and visitors from injury and loss of and visitors from injury and loss of
system designed to organizationorganization, its employees patients , its employees patients , its employees patients and visitors from injury and loss of and visitors from injury and loss of
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Iatromics project
What is a Near Miss?
A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage
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What is an Adverse event?
An Adverse event is any adverse change in health or side effect that occurs in a person who participates in a clinical trial, while the patient is receiving the treatment (study medication,
application of the study device, etc.).
Frankenstein junior
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Iatromics project
What is a Sentinel Event?
A Sentinel Event is defined by The Joint Commission as any unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's
illness. •! Procedures involving the wrong patient or body part
resulting in death or major permanent loss of function •! Suicide in an inpatient unit •! Retained instruments or other material after surgery
requiring re-operation or further surgical procedure •! Intravascular gas embolism resulting in death or
neurological damage •! Haemolytic blood transfusion reaction resulting from ABO
incompatibility •! Medication error leading to the death of patient reasonably
believed to be due to incorrect administration of drugs •! Maternal death or serious morbidity associated with labour
or delivery •! Infant discharged to wrong family •! Other catastrophic event
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Iatromics project
Causes of adverse events
Learning, culture organization
Adverse Event
Learning, culture organization
Adverse Event
Complexity of health
organizations
Patient, cure and care, work environment
Organization and management
Direct (or immediate) causes
Indirect (or deep) causes
Root causes
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Iatromics project
Starting conditions of the process
Maurizio Musolino Correct Outcome
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Iatromics project
Maurizio Musolino Maurizio Musolino
Starting conditions of the process (small differences in starting time)
Adverse Event
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Iatromics project
A case report: Surgery preoperative check list
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Iatromics project
Different approaches to clinical risk management
•! Protective approach: Good medical/nursing practices, guidelines, scientific raccomandations
•! Reactive approach: Ishikawa graph, London Protocol, Root Cause Analysis
•! Proactive approach: Process analysis HFMEA
•! Predictive approach: Modeling System, Artificial Neural Network, Fuzzy logic, Genetic Algorytm
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Proactive approach Health Failure Mode and Effects Analisys
Iatromics project
Reductionistic and deterministic process analisys
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Iatromics project
A case report: HFMEA of Central Venous Catheter
A.! Grading of patient according to selected criteria.
B.! Preparation of materials and devices.
C.! Preparation of the patient.
D.! Catheter insertion. E.! X-ray control.
B
C
D
E
Priority of Risk Index (score range: 1 – 1000) Severity of damage X Probability of occurrence X Detectability during the occurrence
score: 1 - 10 score: 1 - 10 score: 10 - 1
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I.P.R. errori potenziali
Inquinamento batterico
Utilizzo non idoneo dei disinfettanti Incidenti in corso
di venipuntura Scelta di accesso venoso improprio venoso improprio
Inquinamento Inquinamento Inquinamento Inquinamento Inquinamento Inquinamento batterico batterico
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MAP OF THE RISK I.P.R. errori potenziali I.P.R. errori potenziali I.P.R. errori potenziali I.P.R. errori potenziali I.P.R. errori potenziali I.P.R. errori potenziali Priority of Risk Index
Reactive approach Root Cause Analisys
Iatromics project
AnalisysRootIshikawa’s diagram
Pareto’s rule: 20% causes ! 80% effect
Clinical Risk Management “Sushi style!!!” 1953
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Decisions regarding the
strategic processes
Professional and organizational
culture
Conditions leading to errors
Conditions leading to violations
Concomitant factors
errors
violations
Problems caused by clinical
management
Potential conditions of
errors
Concomitant factors causing
errors
Unsafe or insecure Actions
Vulnerability of the barriers
Model representing the chain of Causes of adverse events (by Reason & Vincent – Dpt. Psycology of London College University) (by Reason & Vincent – Dpt. Psycology of London College University)
London protocol
errorsDo you remember the Titanic?
Do you remember the Concordia?
Management, Strategic decisions and organizational processes
Factors related to the work environment
Factors related to the work team
Individual factors
Factors related to the specific duty
Patient’s characteristics
Errors Violations
Startegic and managerial choices, supported by favouring factors, can be causes of errors and violations. These latter could potentially turn into Care Delivery Problems if not neutralized by defensive, protective or organizational mechanisms. Delivery Problems might make the cures
unsafe, and provoke the adverse event.
Barriers
Model representing the organizational causes of adverse event (by Reason)
Iatromics project
Rating Hospital
Risk manager
Near miss Adverse event
Sentinel event
Health Agency
Hospital Root Cause Analysis 1° feed back
(Local)
LAiT Informatics (data base)
Healthcare Ministry (SIMES)
Rating Hospital Sentinel event only
(P.RE.VAL.E) Benchmarking 2° feed back
(Region)
Monitor sentinel event 3° feed back
(Nation)
Healthcare Ministry
Monitor sentinel event start
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Iatromics project
Rating Hospital (P.RE.VAL.E)
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Iatromics project
Rating Hospital (P.RE.VAL.E)
Hospital X
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Iatromics project
NON LINEAR NON DETERMINISTIC
APPROACH
CLINICAL RISK ASSESSMENT
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Ralph Stacey’s matrix
Stacey’s agreement & certainty matrix Adapted from Stacey RD (1999)
agre
emen
t / d
isag
reem
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certainty / uncertainty simplex
cum-plicum cum-plexum
caos ag
reem
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dis
agre
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Uncertainty Area Y=f(?) Caos Area
… ? …
Ralph Stacey’s matrix
cum-plicum cum-plexum
caos
Procedures and guidelines Statistics Linear Flow charts Data from rules
Intuition Model A.I. as decision support Fuzzy Logic (uncertainty) Cognitive maps
Ripetitive patterns Learning from data Rules from data From models of mathemathical functions to simulations with agents
Musolino 2005
ARTIFICIAL ADAPTIVE SYSTEM Massimo Buscema, Marco Intraligi, DEDALO, GESTIRE I SISTEMI COMPLESSI IN SANITA volume 1 - N.2/2003. (p. 27 – 40)
Artificial sciences
Classical computation Natural computation
Descriptive Systems
Programming theory Operative systems Data base Compilers Programming languages "!
Probabilistic theory Catastropher theory Chaos theory Evidence theory Fuzzy logic theory
Generative Systems
Physical systems
Adaptive systems
Evolutionary systems
Learning systems (artificial neural
network)
Fuzzy Logic theory Evolutionary systems
Learning systems (artificial neural network)
Theoretical systems in combined form artificially reproduce the human way of managing the reality.
Iatromics project
A case report: Antibiotic resistance
Microorganisms have the ability to change their genetic heritage is through individual spontaneous mutation or through genetic exchange. This means that the bacteria are available to virtually the entire chromosome complement of all existing microorganisms are the only living things that can have an exchange of genetic material between species. This great opportunity allows bacteria to adapt to any environment, including those dominated and determined by antibiotics.
Culver DH, Horan TC, Gaynes RP, Eykyn SJ, Littler WA, McGowan DA, wound infection rates by wound class, operative procedure and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991; 91: 152-57. wo
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Input Variables 8
Output Variables 3
Intermediate Variables 0
R u l e B l o c k s 3
Rules 50
Membership Functions 27
Fuzzy Wound Infection Risk Index
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NUMBER OF OPERATIONS PERFORMED IN THE OPERATING ROOM TOTAL 5930
EXPECTED VALUE OF NUMBER OF SURGICAL OPERATIONS WITH ANTIBIOTIC PROPHILAXYS N. Operations X Fuzzy Risk Index Infection: 5930 X 0.7 ! 4150
ANTIBIOTIC UNIT PROVIDED TO THE OPERATING ROOM = N ° 5148
Inappropriateness value ! 19% Inappropriateness value ! 19%
A case report: Antibiotic resistance
•! Start DEMING PROCESS Continuos Quality Improvement •! Hospital or Surgery Impatient Unit BENCHMARKING
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Iatromics project
A case report: First Aid Department
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Iatr
omic
s pr
ojec
t B
y M
auriz
io M
usol
ino
Thanks for your attention yourMaurizio Musolino
Learning from the mistakes not to repeat them Learning from the mistakes not to repeat them Learning from the mistakes not to repeat them Learning from the mistakes not to repeat them but ... to invent ever new !!!