systems for safety june 2006. much has been done … trend in age-adjusted 30-day in-hospital death...
TRANSCRIPT
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Systems for Safety
June 2006
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Much has Been Done …Trend in Age-Adjusted 30-Day In-Hospital Death Rate
Excludes NL, QC, BC
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But Challenges Remain
of Canadian adults report that they, or a family member, experienced a preventable “adverse event”
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How often do adverse events happen?
Hospital-acquired infection (kids)
Birth traumaAdults with health problems given wrong medication/dose
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Foreign object left in Infected transfusion blood: HIV
In-hospital hip fractures for seniors
How often do adverse events happen?
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Information for Improvement…
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Data Systems for Safety: Addressing Many Challenges• How do we identify for follow-up:
Patients at risk of adverse events Patients who may have experienced an adverse event
• How do we know the extent of the problem and how it is changing?
• How do we know which changes to try?
• How do we know that change is an improvement?
• How can we demonstrate accountability?
• How do we learn and spread lessons from adverse events or near misses?
• Etc.
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Tracking Progress: Vital Signs
Team by Team
Projectby Project
BigDot
- Overall mortality trends
-Trends in care processes
- Intervention-level outcomes
-Tracking team’s care processes
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Medication Incidents: Example #1
• Information on number, types, sources, causes and outcomes…
• Is needed to Identify areas requiring change Identify potential preventative strategies Assist in implementing strategies that have
been shown to reduce the risk of incidents Evaluate implementation outcomes
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Different approaches for different needs …
Chart reviews
Patient Safety
Surveys Indicators
Reporting Systems
EHR & Decision-support
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Primary Health Care Indicators: Example #2
Type of Data Source Required
Current Data Sourc
es
Modified
Data Sourc
es
Expanded
Data Sourc
es
No Curre
nt Data Sourc
e
Total
Client/patient or population surveys
9
5
17
- 31
Provider survey data
6
4
5
15
Organization survey data
- - 21
2 23
Clinical administrative data
1
3
12
17 33
Other administrative data
2
- - 1 3
TOTAL 18 12 55 20 105
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Information for Improvement
What is the Potential?
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At the Practice LevelCHF Collaborative in BC
Pre Post
% on ACE-I/ARB 24% 93%
% on beta blockers 21% 89%
% self-management goals 4% 57%
Source: http://www.heartbc.ca/pro/collaboratives/chf/docs/chf-finalposter.pdf
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The Pharmanet Story
• Out of 35 million prescriptions in 2003 7.9 million potential interactions flagged 12% “most significant”
– Generally require action to reduce risk of serious adverse event
• Most common reasons for not dispensing as written in 2003 Consulted provider, changed dose/instruction Sub-therapeutic dose Prior adverse reaction
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Adverse Event Reporting
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Informing Management Decisions
• Within a year, 92% of Ontario hospitals had taken action based on data reported in the Hospital Reports
• Common areas for action included improving communication and coordination of care
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30-Day In-Hospital Death Rate Following New Heart Attack Admission
Lowest 7.6%
Overall 11.1%
Highest 16.3%
Regional Differences 2002–2003 to 2004–2005, excluding QC & NL
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The Road Ahead …