Sunday, January 08, 2012

Tracking adverse events

A recent report from the Office of Inspector General at the US Department of Health and Human Services finds, unsurprisingly, that hospital incident reporting systems do not capture most patient harm.  A summary of major points:

All 189 sampled hospitals had incident reporting systems to capture events, and administrators we interviewed rely heavily on these systems to identify problems.

Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm.

Nurses most often reported events, typically identified through the regular course of care; 28 of the 40 reported events led to investigations and 5 led to policy changes.

Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected.

And here are the recommendations:

AHRQ and CMS should collaborate to create a list of potentially reportable events and provide technical assistance to hospitals in using the list.

CMS should provide guidance to accreditors regarding surveyor assessment of hospital efforts to track and analyze events and should scrutinize survey processes when approving accreditation programs.

Sorry, but to me this is all somewhat "ho-hum."  Virtually all adverse event reporting systems are "bolt-on" additions to hospital clinical information systems.  They do not result from a thorough analysis of how work is done on the floors and units of hospitals.  They are not designed by the people who actually have to report such events.  They are certainly not designed to capture near-misses, which occur 100 to 1000 time more often than actual adverse events, but which are a huge source of information about systemic problems.  Filling them out is often considered "extra work" by busy clinicians, not as part of a process of continuous, front-line driven process improvement.  Thus the recommendations offered in the report will not, I predict, make a significant difference in the future.

What are also unsurprising are the findings in this article by Downey et al, covering the period 1998 to 2007:

As the patient safety movement enters its second decade, an emerging body of research is finding that safety for hospitalized patients has likely not improved significantly over the past several years. This study, which used the AHRQ Patient Safety Indicators (PSIs) to analyze safety events in 69 million hospitalizations over a 10-year period, also finds no clear evidence of improved safety. Of the 20 PSIs analyzed, 7 increased in incidence over the time period studied, 7 decreased, and 6 did not change. While PSIs are best used for screening purposes and not for direct comparisons between hospitals, they have been used to track system-level rates of safety problems over time. The results of this study and other recent literature provide continued urgency for the safety movement to strive to improve the safety of the entire health care system.

What's going on? Answer:  We hear of great work done in quality and safety improvement by hospitals on the leading edge.  And that work is often impressive.  But those reports distract us from the fact that most hospitals still do not have in place clinical, administrative, and governance leaders who seriously and consistently put process improvement at the top of their strategic objectives.  As I have mentioned, I am often approached at my speeches by nurse managers and young doctors who say, "How can I get my CEO/Chiefs/Board to support these kind of activities?"

I have urged here my (former) colleagues in academic medical centers to take the lead in these matters. Many, too, have urged the country's medical schools to incorporate the science of health care delivery improvement into their curricula. Thus far, the pace is way too slow. Let's hearken back to Captain Sullenberger's imperative:

""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."


Anonymous said...

There is something gratifying to see in print what we all knew, and said, but was long taboo to agree upon.

What would be bold?
(1) Garner some fraction of current technological transitions to reliably capture a portion of 'overlooked' events to increase the individual cost of moving on to the next patient,
(2) Recruit the interests of those who do not report because of hierarchical concerns by elevating anonymous (provider and reporter) reporting systems (governmental and independent organizations should do this if institutions do not),
(3) Create meaningful local rewards for the humility of making a mistake, and the courage to share it (velocity could be gained from leaders being leaders by doing so first),and,
(4) Centralize patient/family reporting similar to the airline pilot model. If we are talking about it at with such frequency over dinner and the watercooler, why not TwitterHarm?

One or two of them, well executed, would push the behemoth off its spin. It isn't necessary to change everyone's behavior. Just create the unpredictability inherent in a life without immunity. It is the world that most of us live in each day.

Anonymous said...

Paul, you are so right to emphasize the importance of the near miss, and of the front line staff in designing error collection and management. I had a seminal experience as Blood Bank medical director in my hospital, where the process for maintaining patient identification for blood transfusion during surgery was deficient. (Sadly, our hospital had an old history of killing a patient through a transfusion ID error) The OR nurses all knew there was a problem and, individually, had devised workarounds that they thought would compensate - including such things as writing the patient's medical record number on the leg of their scrubs! The OR Director and Nursing VP tried to devise nonworkable solutions off the cuff during a meeting with me in their office - clearly to make me go away as soon as possible.
When I was finally allowed to meet directly with the staff, they arrived at a consensus solution, implemented it and were off and running. Many approached me later expressing gratitude that this worrisome problem had finally been addressed.

Imagine a world where senior management would encourage the relentless identification and front line-driven solution of such accidents waiting to happen. Wouldn't we want that as patients?

nonlocal MD

Keith said...

Once again, until the incentives are changed, do not expect health care administrators to alter their priorities.

Despite the fact that many mission statements of hospitals usually state their missions to preserve life and improve health, their main missions have become one focused more on growth and dollars; just what CEOs are taught to focus on as their priorties. While most corporations would fail with a strategy that increased the cost of its product and reduced the quality, healthcare measures of quality are difficult to obtain, and health insurance shields the consumer from the true cost. Why else do we have waterfalls in hospital lobbies, concierge service at most upper tier hospitals, and a barrage of hospital advertising? Are they really a necesity to the hospitals mission?

I think you constantly show the profound frustartion you undoubetedly experienced in improving the quality at BIDMC, but watching as a probably inferior system in terms of quality ate at your market share as they used their extra premium dollars to buy up more hospitals and doctors practices. It is no fun feeling you are doing the right thing to try to improve healthcare and to watch as others work to shovel more money into their pockets while placing our healthcare system on an unsustainable economic path.

Paul Levy said...

Actually, Keith, I wasn't frustrated at BIDMC, and our market share actually grew substantially as a direct result of our focus on quality, safety, process improvement, and transparency.

Anonymous said...

We have a fabulous high-tech incident reporting system called "Occurrence Insight." It is used mainly by tattle-tales whose feelings have been hurt. Seriously, one nurse recently took some paid time to "write up" another nurse for sighing heavily over the phone.

Yet a medication error near miss that happened during the same month went officially unreported.

Garbage in, garbage out.