Systems for Safety

June 2006

Much has Been Done …Trend in Age-Adjusted 30-Day In-Hospital Death Rate

Excludes NL, QC, BC

But Challenges Remain

of Canadian adults report that they, or a family member, experienced a preventable “adverse event”

How often do adverse events happen?

Hospital-acquired infection (kids)

Birth traumaAdults with health problems given wrong medication/dose

Foreign object left in Infected transfusion blood: HIV

In-hospital hip fractures for seniors

How often do adverse events happen?

Information for Improvement…

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.

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

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

Different approaches for different needs …

Chart reviews

Patient Safety

Surveys Indicators

Reporting Systems

EHR & Decision-support

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

Information for Improvement

What is the Potential?

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

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

Adverse Event Reporting

                                                                                                           

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

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

The Road Ahead …