hot topics in patient safety2/22/2018 1 hot topics in patient safety sally sims, pharmd speaker...

2/22/2018

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Hot Topics In Patient SafetySally Sims, PharmD

Speaker Disclosure

I have no affiliations or significant financial interests with manufacturers of any commercial product and/or providers of commercial services, and am not supported by grants/research support or status as an employee, consultant, major stockholder, or member of a speakers bureau.

Objectives• Outline and understand perspective of regulatory agencies regarding Patient Safety

• Review and acknowledge current methodologies for measuring Patient Safety

• Discuss strategies for prioritizing pharmacy resources in Patient Safety Initiatives

• Examine the Falls Reduction initiative in Patient Safety, highlight the role of medications in Falls, and consider strategies for pharmacy staff interventions

• Explore methods for collecting and quantifying Adverse Drug Events [ADE’s]

• Comprehend current state of nationally targeted ADE management

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Objectives -> Hot Topics• Patient Safety: What is it and how do I know if we have it or not?

• Falls

• Adverse Drug Events [ADE’s]

• Prioritizing Pharmacy Resources

ACPE Definition: Patient Safety

The prevention of healthcare errors, and the elimination or

mitigation of patient injury caused by Healthcare Errors [An

unintended healthcare outcome caused by a defect in the

delivery of care to a patient]

Healthcare errors may be errors of:

• Commission (doing the wrong thing)

• Omission (not doing the right thing)

• Execution (doing the right thing incorrectly)

Errors may be made by any member of the healthcare team in any healthcare setting.

ACPE Policies and Procedures Manual: A Guide for ACPE Accredited Providers. (2017). Retrieved from https://www.acpe‐accredit.org/pdf/CPE_Policies_Procedures.pdf p35.

Active LearningMatch the Type of Error With Its Meaning

Commission

Doing The Wrong Thing

Omission

Not Doing the Right Thing

Execution

Doing The Right Thing Incorrectly

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Patient Safety Organizations• Agency for Healthcare Research & Quality [AHRQ]

https://www.ahrq.gov/

• Institute for Healthcare Improvement [IHI] http://www.ihi.org

• Pennsylvania Patient Safety Authority

http://patientsafety.pa.gov/

Regulatory & Accreditation Organizations

• Centers for Medicare & Medicaid Services [CMS] https://www.cms.gov

• The Joint Commission [TJC] https://www.jointcommission.org

• Centers for Disease Control & Prevention [CDC] https://www.cdc.gov

Regulatory Agencies Perspectives

• CMS adopted Patient Safety Indicators developed by AHRQ

• Affordable Care Act [ACA]

➢ Established Hospital‐Acquired Condition [HAC] Reduction Program

• Requires Secretary of Department of Health and Human Services [HHS] to adjust payments

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• AHRQ Patient Safety Indicators | PSI 90 Composite Score

➢ Pressure Ulcers*

➢ Iatrogenic Pneumothorax

➢ Fall with Hip Fracture*

➢ Peri‐operative:

• Hemorrhage/Hematoma

• Pulmonary Embolism/Deep Vein Thrombosis

• Unrecognized Abdominopelvic Accidental Puncture/Laceration

➢ Post‐operative:

• Acute Kidney Injury Requiring Dialysis

• Sepsis

• Wound Dehiscence

*CMS Nursing Home Quality Measures

https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/Downloads/FY2018‐HAC‐Reduction‐Program‐Fact‐Sheet.pdf


• Hospital‐Acquired Condition Reduction Program 2018

➢ PSI 90 Composite Score

➢ Central Line‐Associated Bloodstream Infection [CLABSI]

➢ Catheter‐Associated Urinary Tract Infection [CAUTI]*

➢ Surgical Site Infection [SSI]

➢ Methicillin‐resistant Staphylococcus aureus [MRSA] bacteriemia

➢ Clostridium difficile Infection [C‐Diff]

*CMS Nursing Home Quality Measures

https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/Downloads/FY2018‐HAC‐Reduction‐Program‐Fact‐Sheet.pdf


CMS Star Ratings

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Active LearningWhich of the following is NOT a Healthcare

Acquired Patient Safety Indicator?

A. Pressure Ulcer

B. Urinary Tract Infection

C. Fall

D. Diabetes

Measuring Patient Safety

• By the Numbers:

• Patient Safety Indicators

• Adverse Drug Events

• By the Culture

• AHRQ Culture of Safety Survey

Measuring Patient SafetyAHRQ Safety Culture Surveyshttps://www.ahrq.gov/sops/index.html

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Measuring Patient Safety

Use AHRQ Safety Culture Surveys To:

• Raise staff awareness about patient safety

• Diagnose and assess the current status of patient safety culture

• Identify strengths and areas for patient safety culture

• Examine trends in patient safety culture change over time

• Evaluate the cultural impact of patient safety initiatives and interventions

• Conduct internal and external comparisons

https://www.ahrq.gov/sops/index.html

Measuring Patient SafetyAHRQ Culture of Safety Surveys

Measure Perceptions of:

• Teamwork

• Communication

• Leadership Support

• Staffing

• Error Reporting

Active LearningAHRQ provides Culture of Safety Surveys for which of the following practice settings?

A. Hospital

B. Nursing Home

C. Community Pharmacy

D. All of the above

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Hot Topic: FALLS

Falls are NOT an inevitable part of aging.

There are specific things that you, as their health care

provider, can do to reduce their chances of falling

https://www.cdc.gov/steadi/index.html

Facts About Falls• A patient fall is defined as an unplanned descent to the floor with or without injury to the patient

• Between 700,000 and 1,000,000 people in the United States fall in the hospital annually➢1 in 4 older adults in community setting➢40‐50% Nursing Home Residents➢Top 1st or 2nd Type Sentinel Event in Hospitalized Patients

• A fall may result in fractures, lacerations, or internal bleeding, leading to increased health care utilization or death

• As of 2008, the Centers for Medicare & Medicaid Services (CMS) does not reimburse for fall related injuries

https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

Facts About Falls


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Facts About Falls

Falls are the leading cause of both fatal and non-fatal injuries among people aged 65 years and older


Falls Reduction Toolkit:Institutional Settings

https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

Falls Reduction Toolkit:Community/Ambulatory Settings


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Falls Reduction Toolkit:Community/Ambulatory Settings

CDC STEADI: Materials for Healthcare Providers


Core Falls Prevention Activities

Screen: Risk Factors

• Age-related decline➢ Changes in visual function➢ Proprioceptive system, vestibular system

• Chronic disease ➢ Parkinson’s disease➢ Osteoarthritis➢ Cognitive impairment➢ Diabetes➢ Cardiovascular disease

• Acute illness

• Medication use

American Geriatrics Society www.americangeriatrics.org|www.geriatricscareonline.org|Falls Prevention

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Screen: Risk AssessmentInstitutional Example

Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3h.html

Morse Fall Scale

Screen: Risk AssessmentCommunity Example


Screen: Risk Factors

• Specific classes, for example:➢Benzodiazepines➢Other sedatives➢Antidepressants➢Antipsychotic drugs➢Cardiac medications➢Hypoglycemic agents

• Recent medication dosage adjustments

• Total number of medications


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Screen:Medication Risk Assessment

Tool 3I: Medication Fall Risk Score and Evaluation Tools. Content last reviewed January 2013. Agency for Healthcare Reseand Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3i.html

Screen:Medication Risk Assessment

Tool 3I: Medication Fall Risk Score and Evaluation Tools. Content last reviewed January 2013. Agency for Healthcare Reseand Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3i.html

Assess:Identify Modifiable Risk Factors

•Treatment goals•Current medication regimen

Include OTC, supplements, allergies, alcohol use, and recreational drug use•Side effects experienced•Non‐pharmacologic options•Patient values and preferences [Handout]•Barriers to care

Low health literacy, physical and cognitive impairment, socioeconomic barriers ‐> medication adherence


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Intervene:Use Clinical & Community Strategies

Use Multifactorial Interventions Including:➢ Minimize medications

• Stop when possible• Switch to safer alternatives• Reduce to lowest effective dose

➢ Develop a monitoring plan for medication side effects

➢ Supplement Vitamin D➢ Manage postural hypotension, and

heart rate and rhythm abnormalities


Intervene:Use Clinical & Community Strategies

Use Multifactorial Interventions Including:➢ Explore non-pharmacologic options to

manage medical conditions• Initiate individually tailored exercise

program• Treat vision impairment

➢ Manage foot and footwear problems➢ Modify the home environment


THINK - PAIR - SHARE

Pair up in groups and discuss:

1. What toolkit resource is most applicable for my practice setting?

2. What is the current status of a falls prevention initiative in my practice setting?

3. What one thing can I do when I go back to work to advance falls prevention activities in my practice setting?

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THINK - PAIR - SHARE

Potential Discussion Answers:

• Institutional ‐ AHRQ

• Community/Ambulatory ‐ CDC STEADI

• Not started | Early Stages | Advanced

• ID workflow options to incorporate | Talk to my supervisor | Develop/Adopt a risk assessment tool

Hot Topic: ADE’s"Our figures show approximately four

and one half million hospital admissions annually due to the adverse reactions to

drugs. Further, the average hospital patient has as much as thirty percent

chance, depending how long he is in, of doubling his stay due to adverse drug

reactions." Milton Silverman, M.D. (Professor of

Pharmacology, University of California)

Collecting & Quantifying ADE’SIn order to solve a problem you must first define it

and accurately quantify it

• Adverse Drug Event (ADE): an injury to a patient resulting from a medication intervention, which can occur in any health care setting

• Reporting: ➢ Systems, Data, & Culture

• Systems: Paper, Database, E‐mail?

• Data: Where does info go and who manages it?

• Culture: Punitive, Blame Free, Just Culture?

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Collecting & Quantifying ADE’S:Quantify and Prioritize Collected Data

http://www.nccmerp.org/sites/default/files/indexColor2001‐06‐12.pdf

Collecting & Quantifying ADE’S

Prioritize➢ Severity: Signal or Sentinel Event

➢ High Risk• High Alert Medications

• Look‐A‐Like Sound‐A‐Like

• Hazardous Medications

• Regulatory

➢ Trends

➢ Targeted Initiatives

• [Opioids, Anticoagulants,Hypoglycemia]

CMS Targeted ADE Management:

The Centers for Medicare & Medicaid Services awarded the Health Research & Educational Trust (HRET) a two‐year HIIN Hospital Improvement Innovation Network (HIIN)contract (with an optional third year based on performance), to continue efforts to reduce all‐cause inpatient harm by 20 percent and readmissions by 12 percent by 2018

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-09-29-2.html

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Health Research & Educational Trust (February 2017). Adverse Drug Events Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org

• The Office of Disease Prevention and Health Promotion (ODPHP) released The National Action Plan for ADE Prevention (ADE Action Plan) in October 2014.

• The report focused efforts on the group of ADEs that are common, clinically significant, preventable and measurable.


Health Research & Educational Trust (February 2017). Adverse Drug Events Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org

» ADE Targets• Anticoagulants ‐

Bleeding

• Diabetic Agents ‐Hypoglycemia

• Opioids ‐ Overdose, Over Sedation, Respiratory Depression, Death

Prioritizing Pharmacy ResourcesGroup Discussion

Within scope of pharmacy practice

Accreditation Standard

CMS Priority

Severity of Harm

Frequency of Events

Cost of Intervention

Impact on Workflow

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