ERIC V. JACKSON, JR., MD, MBA
ASSOCIATE DIRECTOR, VALUE INSTITUTE DIRECTOR, HEALTH CARE DELIVERY SCIENCE
CHRISTIANA CARE HEALTH SYSTEM ADJUNCT – FACULTY, JOHNS HOPKINS SCHOOL OF MEDICINE
The Science of Safety: Creating Systems of Profound Knowledge
No Disclosures
Basic ResearchMolecular and Cellular BiologyPhysiology and GeneticsNeurosciences
Translational ResearchDisease MechanismsDisease ModelsDrug DiscoveryClinical Studies
Clinical Research/TrialsDrug TrialsVaccine TrialsDevice Trials
TraditionalModel
Discovery Increasing Amounts of Information
Institute of Medicine, Sept 2012
International Comparison of Spending on Health, 1980–2009
0
1000
2000
3000
4000
5000
6000
7000
8000
1980 1985 1990 1995 2000 2005
United StatesNorwaySwitzerlandCanadaNetherlandsGermanyFranceDenmarkAustraliaSwedenUnited KingdomNew Zealand
0
2
4
6
8
10
12
14
16
1980 1985 1990 1995 2000 2005
United StatesFranceSwitzerlandGermanyCanadaNetherlandsNew ZealandDenmarkSwedenUnited KingdomNorwayAustralia
Average spending on health per capita ($US PPP)
Total expenditures on health as percent of GDP
SOURCE: Organization for Economic Cooperation and Development, OECD Health Data 2011 (June 2011).
Premiums Rising Faster Than Inflation and Wages
0
25
50
75
100
125
2000 2001 2002 2003 2004 2005 2006 2007 2008* 2009*
Insurance premiumsWorkers' earningsConsumer Price Index
1112
1314
1617
18 18 18 1819 19 19
20 2021 21
22 2223
24
18
0
5
10
15
20
25
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
* 2008 and 2009 NHE projections. Source: K. Davis, Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums, (New York: The Commonwealth Fund, Aug. 2009).
Projected Average Family Premium as a Percentage of Median Family Income,
2008–2020
Cumulative Changes in Insurance Premiums and Workers’ Earnings,
2000–2009
Percent Percent
108%
32%
24%
Projected
To Err is Human…
98,000 preventable deaths/yr from medical errors in the United StatesCosts of Errors – Estimated at $17-29 billion/year
Institute of Medicine Report - 1999
Mortality from Amenable Causes in Four Countries for People under 65 (1999 – 2007)
Health Affairs, Sept 2012
“Health care may be the most entrenched, change-averse industry in the United States”
CLAYTON M. CHRISTENSENCIRCA 2000 -
HARVARD BUSINESS SCHOOL
An institutional approach is needed
Defining the Triple Aim
Improving the individual (patient) experienceImproving the health of populationsReducing the per capita costs of care for populations
Health Affairs May/June 2008
Donald Berwick, M.D.Senior Fellow Center for American Progress
Centers of Excellence
System Level Perspective
Swiss Cheese Model of Error
Accident Theories
Normal Accident Theory (NAT)-Perrow
2 main elements2 main elementsComplexityTight coupling
High Reliability Organization (HRO) theoryComplex, high-hazard organizations that maintain low failure rates relative to risks
Characteristics of High Reliability Organizations
Safety as highest priorityPreoccupation with failureOpen environment for discussing errorCommunication that permits/encourages all in command hierarchy to speak upRewards for safety actions
Heavy reliance on training for Heavy reliance on training for hazardous situationshazardous situations
What is preventable harm?
“limited empirical evidence of the validity and reliability of the available definitions of preventable harm”
Nabhan et al. BMH Health Services Research 2012 12:128
The Seven Themes of Preventable Harm
1. 44% - Presence of an identifiable modifiable cause2. 23% - Reasonable adaptation to a process will
prevent future recurrence3. 16% - Lack of adherence to guidelines implies
preventability 4. 7% - Morbidity adjusted risk estimates using
observed over expected models to account for preventable vs. inevitable harm
5. 6% - All harm is preventable6. 2% - Comparison with another cohort shows different
incidence7. 2% - Historical comparison (events with declining
incidence over time)Nabhan et al. BMH Health Services Research 2012 12:128
n =127, (Jan 2001 –Jun 2011)
A Classification for Unsafe Acts
Unsafe acts
Unintende d
ActionLapse
Violation
Mistake
Memory failures
Attentional failuresSlip
Intended action
Rule-based mistakesKnowledge-based mistakes
Routine violationsExceptional violationsActs of Sabotage
BasicErrorTypes
Why do hospitals fail to learn from failure?
Case Study
A Harvard Business School doctoral candidate performed an in-depth study on work system failures on the front lines of care delivery in hospitalsOnly hospitals with national reputations for nursing excellence were chosen (magnet, etc.)Qualitative data from 239 hours of observation of 26 nurses at 9 different hospitals were obtained.
California Management Review, Winter 2003
Case Study (cont.)
Key Definitions
Two types of process failures defined & observedError – the execution of a task that is either unnecessary or incorrectly carried out and that could have been avoided with appropriate distribution of pre-existing information.Problem – a disruption in the worker’s ability to execute a prescribed task because either something the worker needs is unavailable in the time, location, condition, or quantity desired and, hence , the task cannot be executed as planned; or something is present that should not be, interfering with the designated task.
California Management Review, Winter 2003
Case Study Results
Results (194 failures observed)
Five broad types of problems (n=166)1. Missing or incorrect information2. Missing or broken equipment3. Waiting for a (human or equipment) resource4. Missing or incorrect supplies5. Simultaneous demands on their time
Three broad types of errors (n=28)1. Errors made by nurse2. Errors made by other people3. Unnecessary execution of tasks resulting from faulty process
flows
California Management Review, Winter 2003
Study Conclusions
First-order problem solving (avoid)Second-order problem solving (promote)
33 minutes per 8hr/nursing shift were lost coping with preventable system failures.
California
Management Review, Winter 2003
Three Positive Human Attributes that Prevent Organizational Learning
Individual VigilanceNursing units designed to maximize individual unit efficiency.Empowerment of workers
California Management Review, Winter 2003
How should we measure preventable harm ?
Is patient harm preventable or inevitable?
Spectrum of medical errors as defined by egregiousness and contribution to outcome
Blameworthy
Not Blameworthy
Coincidence Direct Cause
amputation ofamputation ofthe wrong legthe wrong leg
Death after inpatient CPR with Death after inpatient CPR with right bronchus intubationright bronchus intubation
Death with coagulopathyDeath with coagulopathyand no thoracentesisand no thoracentesisto check for empyemato check for empyema
Second heart attack Second heart attack with no with no ββ
blocker blocker after 1after 1stst
heart attackheart attack
Eff Clin Prac. 2000;6:261-269
Contribution to Outcome
Potential Measurement Strategies
A High-Sensitivity – Low-Specificity StrategyAssume all harm is preventableLink care received to outcome
A Low-Sensitivity – Low-Specificity StrategyAdjust for preventability
The Way Forward
Develop scalable measuresMake estimates of measurement error transparentSeparate hospital efforts to learn from policy efforts to judge.
Nice try…that’s great theory but…. I need something actionable!!
IHI Global Trigger Tool
Automation of measuresNurse Review – Physician Oversight
Trigger Tool6 Modules
Care(all records)
Medication(all records)
SurgicalIntensive
Care
Perinatal
Emergency Department
Concurrent Use of Global Trigger Tools
Leading Indicator:
Measures things that
are in some way a
precursor to harm
Lagging Indicator:
Direct measure of
harm
Trajectory of Care…..Leading and Lagging Indicators
Patient Harm
Leading Indicator
Lagging Indicator
Examples of Leading Indicators
Clostridium difficile positive stoolPTT greater than 100 secondsINR greater than 6Glucose less than 50 mg/dlRising BUN/Serum Creatinine two times over baselineDVT Prophylaxis not ordered for a high risk patient
Level Description Event
A Circumstances or events occurred that had the capacity to cause error.
Harm does not reach patient
B Error occurred but did not reach the patient.
C Error occurred that reached the patient but did not cause patient harm.
D Error occurred that reached the patient and required monitoring to preclude harm or confirm that it caused no harm
E Error occurred that may have contributed to or resulted in temporary harm and required intervention
Harm reaches patient
F Error occurred that may have contributed to or resulted in harm and required an initial or prolonged hospital stay.
G Error occurred that contributed to or resulted in permanent patient harm.
H Error occurred that required intervention to sustain the patient’s life.
I Error occurred that may have contributed to or resulted in patient death
The NCC MERP Index for Categorizing Errors
IHI Global AHRQ Patient Hospital VoluntaryTrigger Tool Safety Indicators Reporting System
IHI Severity LevelE (temporary harm) 204 23 0F (temporary harm) 124 7 2G (permanent harm) 8 1 2H (sustain life) 14 0 0I (death) 4 4 0Total 354 35 4
HospitalHospital A 161 13 0 Hospital B 92 13 3Hospital C 101 9 1Total 354 35 4
Health Affairs 30,4(2011) 581-589
90 seconds
Pronovost, National Press Club, Sept 2012
Clinical Complexity
ICU physicians have 180 activities per patient per dayChronic Disease: a 79 year old patient with osteoporosis, osteoarthritis, type 2 diabetes, hypertension, and chronic obstructive pulmonary disease: 19 medications per day
Institute of Medicine, Best Care at Lower Cost Report, 2012
INR
GLU
BUN
Re- admit
ADT admit
lab results
lab results
lab results
encounters
patient of interest
“POI alert”order to
nursing PAL
Q4h reportemailed
pager alert
dashboarddisplay
CommunicatePOI
Reportable data
Triggers
Work Processes
Analytics
POI
Nursing PAL alert
29-Mar-2012 12:33PowerChart Patient AlertFIN/ECD: 987654321DOB: 3/7/1965 FemaleUnit: C3D 3C01 AINR: 8Resulted: 12:30 03/29/2012
Thu. Mar 29, 2012
Paging of POI Alerts
Use of the Modified Early Warning Score Decreases Code Blue Events
Jt Comm J Qual Patient Saf 2010;35(12):598-603
Prediction of cardiac arrest in critically ill patients presenting to the ED using a machine learning HR variability score vs. MEWS
Critical Care 2012, 16R108
Integration of Early Physiological Responses Predicts Later Illness Severity in Preterm Infants (Physiscore)
APGAR(standard of care)
CRIB SNAP-II SNAPPE-II Physiscore
Time from birth
5 mins 12 hours 12 hours 12 hours 3 hours after birth
Accuracy 0.69 0.85 0.82 0.87 0.91
Effort Manual Manual Manual Manual Manual
Invasive Testing X X
Sci Transl Med 2, 48ra65 2010
• Identifies premature infants at risk for major complications• Useful for resource allocation, managing infant transport, staffing-ratio
Sci Transl Med 2, 48ra65 2010
29-Mar-2012 12:33PowerChart Patient AlertFIN/ECD: 987654321DOB: 10/7/2012 FemaleUnit: C3D 3C01 AEarly Sepsis Warning (hisk risk) start ABX & Fluid now!!, may arrest in 10 hours, Activate Sepsis mobile appResulted: 12:30 03/29/2012
Thu. Mar 29, 2012
Paging of POI Alerts
Thank You
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