Thanks for Asking! A Family-Initiated Adverse Event Reporting System

Mark AnserminoDonna TackJeremy Daniels

Department of Anesthesiology & Partners in Care BC Children’s Hospital, Vancouver, British Columbia, Canada

Our Team

Mark Ansermino – Anesthesiologist, BCCH Anesthesia Director of Research

Donna Tack – Parent of child-patient, Co-Chair BCCH Partners in Care committee

Jeremy Daniels – Cardiology patient (most of life), BCCH Anesthesia Research Engineer

Katrina Verschoor – BCCH Nursing Leader, Quality & Safety

I have made MISTAKES

I am not badI care about every patientI am human…..

Introduction: Patient Safety

Important term: adverse event

Adverse event: – an injury caused by

medical management

– that prolonged hospitalization, or

– produced disability

History

Lucian Leape’s work in early 1990’s

Reviewed 30 000 NY hospital charts

Adverse event in 3.7% of charts!*

Big opportunity for both hospitals and patients

But this is 2007, and we don’t live in NY!

*N Engl J Med. 1991 Feb 7;324(6):370-6.

Closer to Home

1990’s: people began listening

2004: 15 Canadian researchers from BC to NS

Looked at adverse events in Canada

Found adverse event in 7.5% of hospital admissions*

*CMAJ. 2004 May 25;170(11):1678-86

This is a BIG problem

1.1 million added days in hospital and $750 million in extra healthcare spending

185,000 adverse events per 2.5 million hospital admissions in Canada per year of which close to 70,000 are preventable

More Canadians die due adverse events in hospitals than from breast cancer, motor vehicle accidents or AIDS

Canadian Institute for Health Information. Ottawa, ON; 2004

Key ConceptsKey Concepts

Increasing technology = more errors Most errors do not result in harm (latent

error) Many serious errors preceded by near

misses Errors of omission (neglecting to do

something) are most common Many errors are preventable

What can we do about it?What can we do about it?

Unlikely to be achieved by trying harder!

Culture of SafetyCulture of Safety

Measurement and Evaluation

Legal/Regulatory

Education and Professional Development

Information and Communication

System Changes to

Create a Culture of

Safety

Standard Initiatives

Learn from high-reliability industries– Aviation– Nuclear

What makes it so safe to fly?

Why is your car safe?

Key Technique: Reporting

Reporting system for accidents / near-misses

Understand what’s going on

Redesign system You cannot manage

what you cannot measure!

Families know!

Idea: join hands with families

Have families help identify adverse events

Families complete questionnaire

Families a valuable source of knowledge

Family Reporting of AE

Capitalize on family knowledge / passion to help

Anonymity by default Opportunity to participate in

solution design meetings Provide input for real,

lasting change ? Change the culture ? Improve resilience

Our beliefs about familyOur beliefs about family

Family members: Are key partners in the provision of

safe care Are knowledgeable about what we are

doing well and where improvements can be made

Have numerous personal stories that can be shared for the purposes of organizational learning and improvement

Want to be involved in making healthcare safer for everybody

Are an incredible source of knowledge

What we encourage families and patients What we encourage families and patients to reportto report

Anything that is an actual or potential safety concern (mix-ups, near misses, communication breakdown, degree of inclusion and knowledge sharing, discharge planning / preparedness etc.)

Ethical ConsiderationsEthical Considerations

Patient / family confidentiality Organizational responsibility for follow-up on

reports Do we have a process in place for triaging and

ensuring all reports are handled accordingly? Joint reporting processes: Who is in the best

position to be the primary “owners” of the data and “initiators” of change?

Canadian Patient Safety Institute (CPSI)Canadian Patient Safety Institute (CPSI)

The VisionThe Vision

“We envision a Canadian health system where patients, providers, governments and others work

together to build and advance a safer health system; where providers take pride in their ability to deliver the safest and highest quality of care possible; and where every Canadian in need of healthcare can be

confident that the care they receive is the safest in the world.”

http://www.patientsafetyinstitute.ca/about.html

Practical Steps….Practical Steps….

Culture is what people do when no one is looking!

A thought to leave you with…A thought to leave you with…

The true measure of quality is the The true measure of quality is the satisfaction of the receiver of the satisfaction of the receiver of the care, not the satisfaction of the care, not the satisfaction of the

care provider!care provider!

Shifting gears

Donna Tack now– Practical strategies for families

Medication Safety

A Parents Point of View

Challenges

As a parent of a chronically ill child, keeping track of and managing administration of your child’s medications can be daunting.

Ensuring correct dosages and times of administration are observed when there are multiple caregivers

Ensuring all healthcare providers are aware of all medications your child is using prior to prescribing additional medications.

Being aware of all common side effects and drug interactions.

How do I do it?

When your child’s physician prescribes a drug ask:Why this drug?How much and when?Common side effects? If cost is an issue, ask if there is a generic brand that

is EQUALLY as effective. If so, ask the doctor to write the prescription to reflect that.

When having the prescription filled out at the Pharmacy ask for a medication information printout.

Ensure the dosage and directions are correct on the label. Check your child's name, the route (oral, G-Tube, J-tube) and the amount of times per day the medication is to be given.

Ask if there are any refills – if not, make sure you contact the doctor in plenty of time for one. This ensures no doses are missed.

Make the pharmacy aware of all the medications' your child is currently taking – they may not have it on file if you use more than one pharmacy. The pharmacist can answer any questions you might have about drug interactions.

Make the pharmacist your ally, explain that your child is on multiple medications and you would appreciate them letting you know if they see any potential dangers, or even suggestions on ways to administer the medications that are more effective.

Keeping Track

Get a binder and alphabetized tabs to keep drug information printouts organized. It is a simple way to look back at each drug if you have questions or concerns.

Create a simple spreadsheet to keep track of medication administration

(Medication Administration Record or M.A.R.)

Have a medication sheet that lists the dosages (including milligrams per ml), times of day, and all over the counter (OTC) drugs your child may be on. This can be given to your child's health care providers at clinic visits and emergency admissions.

Keep it up to date!!

Seems like a lot of work to me!

It is time consuming – AT FIRST – to set up some of these systems at home, but after the templates are set up, it is a simple matter of the occasional date change or dosage update.

If you aren’t computer savvy, ask a friend, family member or co-worker to help you set up the worksheets. Only a basic knowledge of Word and Excel are needed.

Why do it?

The most obvious – the SAFETY of your child! Ensuring that there is never a medication you or a caregiver

have forgotten to give or not informed the doctors about. When you attend a doctors appointment or have an

emergency admission you are not wasting time trying to recite and remember all the medications, dosages and times of your child's medications. You can simply make the best use of your and the healthcare providers time.

It shows that you are serious about taking charge of your child's health and expect to be seen as a valued member of your child’s healthcare team.

How can I help?

As a health care provider working closely with families, you can help with patient safety in the following ways:

When prescribing new drugs or treatments ensure the patient/caregiver understand completely the dosages, times, side effects and duration of treatment for each medication.

In the Clinic

Offer the patient/caregiver a pen and paper for note taking

Encourage them to ask any questions they may have regarding the medication or treatment. Encourage them to write the answers down.

Although time is usually an issue, try not to appear rushed – this makes most patients and their caregivers nervous and they will generally not ask questions they may have about medications/treatments.

On the Ward

If there is more time for you to spend with the patient/caregiver you could make suggestions about managing multiple medications using the examples that were previously shown.

When bringing medications' for administration, ask the parent/caregiver to double check the medication type and dose. This helps the parent feel like they are a part of the team and is a double check against errors.

If the parent has never administered this medication or treatment before, allow them to give the medication/treatment with your guidance. This helps build confidence for when they are at home.

Be aware of resources available to families in regard to teaching and support. For example – Tube feeding guidelines book for families dealing with a new tube insertion

Is there a family resource library in your hospital? A parent advisory committee, or groups dedicated to a certain diagnosis? Handouts or information pamphlets available on the ward or in the hospital that may be of interest to the families.

Why do it?

Education = empowerment. As families are asked to take a greater role in the health

care system, we must provide them with as much knowledge as possible.

It may seem time consuming at first, but I strongly believe that taking the time to educate and empower families, will result in better management in the home and less frequent hospital admissions.

If parents are able to arrive at the hospital prepared for clinic visits and admissions with medication lists and pertinent information regarding their child, valuable time will be saved.

When parents and caregivers are respected and treated as part of the health care team, they can be a valuable resource, providing information and insight not possible for a health care providers point of view.

If we all work together with the common goal of patient safety, we WILL succeed!