Implementing and Evaluating a Program of

Patient Safety

Katherine Jones, PhD, PTAnne Skinner, RHIAGary Cochran, PharmDKeith Mueller, PhDSupported by AHRQ Grant 1 U18

HS015822

Successful Reporting Systems as the Foundation

2

ObjectivesObjectives

Explain the role of voluntary reporting systems in a program of patient safety

Identify the characteristics of successful reporting systems

Identify information necessary for systematic data collection in a medication error reporting program

Understand how the NCC MERP Taxonomy of error severity provides a language to describe errors in the context of a system

3

The Problem…The Problem…““The problem is not bad people; The problem is not bad people; the problem is that the system the problem is that the system needs to be made safer . . . needs to be made safer . . . Voluntary reporting systems are Voluntary reporting systems are an important part of an overall an important part of an overall program for improving patient program for improving patient safety and . . . have a very safety and . . . have a very important role to play in important role to play in enhancing an understanding of enhancing an understanding of the factors that contribute to the factors that contribute to errors.”errors.” To Err is Human: Building a Safer To Err is Human: Building a Safer Health SystemHealth System

4

Reporting is the foundation Reporting is the foundation of a culture of safetyof a culture of safety

“Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture—an organization in which people are prepared to report their errors and near-misses.”

5

INFORMED = SAFEINFORMED = SAFE

LEARNINGLEARNING

FLEXIBLEFLEXIBLE

JUSTJUST

REPORTINGREPORTING

A culture of safety is informed. It never forgets to be afraid…

Components of Safety CultureComponents of Safety Culture

Reason, J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited; 1997.

6

Reporting is supported by Reporting is supported by just, flexible, and learning just, flexible, and learning

culturescultures The willingness of workers to report depends on

their belief that management will support and reward reporting and that discipline occurs based on risk-taking…there is a clear line between acceptable and unacceptable behavior workers—organizational practices support a just culture.

The willingness of workers to report depends on their belief that authority patterns relax when safety information is exchanged because managers respect the knowledge of front-line workers—organizational practices support a flexible culture.

7

Reporting is supported by Reporting is supported by just, flexible, and learning just, flexible, and learning

culturescultures Ultimately, the willingness of workers to report

depends on their belief that the organization will analyze reported information and then implement appropriate change—organizational practices support a learning culture.

The interaction of practices that support reporting, just, flexible, and learning cultures produces an informed, safe organization that is highly reliable.

The organizational beliefs and practices associated with these components of culture are assessed by the AHRQ HSOPSC.

8

Characteristics of Successful Reporting Systems

Nonpunitive: reporters do not fear punishment as a result of reporting Confidential: identities of reporter, patient, institution are never revealed to a 3rd party Independent: reporting is independent of any authority who has the power to discipline the reporter Expert analysis: reports are analyzed by those who have the knowledge to recognize underlying system causes of error Timely: reports are analyzed promptly and recommendations disseminated rapidly Systems-oriented: recommendations focus on systems not individuals Responsive: those receiving reports are capable of disseminating recommendations

Leape, LL. (2002). Reporting of adverse events. NEJM, 347, p. 1636.

9

MEDMARXMEDMARX® MEDMARX is an anonymous medication error reporting program that subscribing hospitals and health systems participate in as part of their ongoing quality improvement initiatives. Nationally, data from MEDMARX contributes to knowledge about the causes and prevention of medication errors. Over 870 hospitals and health systems have submitted more than 1.3 million medication error records to MEDMARX. Analyses of voluntary medication error reports from large patient safety databases, such as MEDMARX, can identify system sources of error and lead to the establishment of safe medication practices.Stevenson JG. Medication errors: Experience of the United States Pharmacopeia. Jt Comm J Qual Safe 2005;31(2):106-111.

10 www.MEDMARX.com

11

Systematic Data Collection Systematic Data Collection in Medication Error in Medication Error

ReportingReporting Error severity based on the outcome to

patient Description of the error Phase of the medication use process in

which the error originates Type of the error Cause of the error Contributing factors to the error Information about the drug(s) involved

12

NCC MERP Taxonomy of NCC MERP Taxonomy of Error Severity Error Severity

A: capacity to cause errorA: capacity to cause error B: error occurred, did not reach patientB: error occurred, did not reach patient C: error reached patient, no harmC: error reached patient, no harm D: error reached patient, monitoring and D: error reached patient, monitoring and

intervention requiredintervention required E: temporary harm requiring interventionE: temporary harm requiring intervention F: temporary harm requiring initial or F: temporary harm requiring initial or

prolonged hospitalizationprolonged hospitalization G: permanent harmG: permanent harm H: intervention required to sustain lifeH: intervention required to sustain life I: error contributed to or resulted in deathI: error contributed to or resulted in death

http://www.nccmerp.org/pdf/taxo2001-07-31.pdf

13

14

Reporting Error SeverityReporting Error SeverityError Severity Jan - June 2007 (31 CAHs submitted 2,799 reports)

C (reaches pt, no harm)50%

B (near-miss)20%

A (potential error)28%

D (reaches pt, monitoring)

2%

F (harm, hospitalization)

0%E (temporary harm)

0%

15

Reporting Where Errors Reporting Where Errors OriginateOriginate

Phase of Error Origination Jan - June 2007 (31 CAHs submitted 2,799 reports)

Prescribing5%

Documenting26%

Dispensing10%

Administering58%

Procurement1%Monitoring

0%

16

Reporting Reporting Types of Types of ErrorsErrors

Jones et al. (2006). http://www.unmc.edu/rural/documents/pr06-08.pdf

17

Reporting CausesReporting CausesCauses of Errors Errors (B -I) Jan 2005 - June 2007

0%

5%

10%

15%

20%

25%

Pro

ced

ure

/pro

toco

ln

ot f

ollo

we

d

Pe

rfo

rma

nce

/hu

ma

nd

efic

it

Tra

nsc

rip

tion

ina

ccu

rate

/om

itte

d

Do

cum

en

tatio

n

Co

mm

un

ica

tion

Wo

rkflo

w d

isru

ptio

n

Co

mp

ute

r e

ntr

y

Dru

g d

istr

ibu

tion

syst

em

Wri

tten

ord

er

MA

R v

ari

an

ce

Re

con

cilia

tion

ad

mis

sio

n

Dis

pe

nsi

ng

de

vice

Kn

ow

led

ge

de

ficit

Do

sag

e fo

rmco

nfu

sio

n

Sim

ilar

pro

du

cts

2005 (25 CAHs, 3,897 reports) 2006 (35 CAHs, 4,197 reports) 2007 (31 CAHs 2,799 reports)

18

Reporting Contributing Reporting Contributing FactorsFactors

Contributing Factors to Errors (B -I) Jan 2005 - June 2007

0%

5%

10%

15%

20%

25%

30%

35%

Dis

tra

ctio

ns

Wo

rklo

ad

incr

ea

se

Sta

ffin

exp

eri

en

ced

No

24

ho

ur

ph

arm

acy

No

ne

Sh

ift c

ha

ng

e

Pa

tien

t tra

nsf

er

Em

erg

en

cysi

tua

tion

Sta

ffin

g in

suffi

cie

nt

Sta

ff a

ge

ncy

,te

mp

ora

ry

Ra

ng

e o

rde

rs

2005 (25 CAHs, 3,897 reports) 2006 (35 CAHs, 4,197 reports) 2007 (31 CAHs 2,799 reports)

19

What we heard about using What we heard about using MEDMARX as the foundation MEDMARX as the foundation for reporting in Critical for reporting in Critical Access Hospitals: Access Hospitals: “Before the project, we just counted errors.

We never went past the type of error.” “Using MEDMARX increased reporting

because people had more knowledge that what we are doing is intended to make the system safer.”

“Using the lingo of MEDMARX, errors got broken down into categories that even the board could understand so they were more open to thinking about allocating money for an automated dispensing system.”

20

What we heard What we heard continued…continued…

““Without the language of errors associated Without the language of errors associated with MEDMARX, all we could talk about was with MEDMARX, all we could talk about was who did it and not what happened and why. who did it and not what happened and why. MEDMARX created a standardized process MEDMARX created a standardized process that allowed us to collect more information. that allowed us to collect more information. The use of MEDMARX and its graphs and The use of MEDMARX and its graphs and charts contributes to the perception of errors charts contributes to the perception of errors as having a system source.”as having a system source.”

““Because we were able to visualize the system Because we were able to visualize the system through the graphs and charts, we could through the graphs and charts, we could communicate to staff and take action.”communicate to staff and take action.”