Quality ColloquiumAugust 22, 2005

REDUCTION OF ADVERSE DRUG EVENTS

Kathy HaigDirector Quality Resource Management

Risk Manager/Patient Safety Officer

OBJECTIVES

Introduce process changes that contribute to reduction of adverse drug eventsDiscuss the impact of culture on medication event reduction effortsReview tools used in process improvement collaborativeLearn about Medication Reconciliation

OSF ST. JOSEPH MEDICAL CENTER

Located in Bloomington, IllinoisServes a community of 100,500 peopleLicensed for 157 bedsProvides Open Heart Surgery Services

Started “Beating Heart” Program in 19995 Hospital-Owned Physician Office PracticesUrgent Care CenterLicensed as a Level II Trauma Center

GOALS

Maintain a cultural survey score above 4Involve patients with safetyConduct 3 phases of med reconciliation Decrease the Dispensing and Ordering FMEAPromote Dosing Service for AnticoagulantsDeploy Pharmacy Based Order SetsComply with JCAHO Patient Safety GoalsSafety tool kit (RCA, FMEA, Human Factors, CAS, TRM)

ADE’S / 1000 DOSES

OSF St. Joseph Medical Center

Events/1000 Days

0255075

100125150175200225250

Jun-04

Jul-04Aug-04

Sep-04Oct-04

Nov-04

Dec-04Jan-05

Feb-05

Mar-05

Apr-05May-05

Date

Eve

nts/

1000

day

s

SJMC

Idealized Design of the Medication System

Key Areas of FocusCultureReconciliationDispensing OrderingHigh Risk Medications

Cultural Transformation

Improve Safety Climate or culture Cultural survey or safety climate score

Focus on harm, not errors Meaningful, avoids blame game

Focus on process and systemPoor processes; not “bad people”

Focus on communication and teamwork

High Reliability

Medication System

Safer Core ProcessesSafer Core Processes• RCA•FMEA •Simulation •CRM • CAS •Human factors

Leadership Driven Culture of SafetyLeadership Driven Culture of Safety

Collaboration. System thinking Focused on Change Evidence

Patient Involvement

High Reliability Characteristics

Preoccupation with failureIs 80% good enough?

Deference to expertiseMost knowledgeable takes charge regardless of role

Ask yourself:What have I missed today?What should I have seen that I didn’t?

STARTING THE JOURNEYCULTURE

System ThinkingInfluenced by patient condition, tasks, staff, environment, teamwork, management

CollaborationFriendly competition; accomplish more, faster

Commitment to ChangeNew, better ways; test ideas

Evidence BasedOrder Sets; Protocols

CULTURESTAFF INVOLVEMENT

Non-Punitive Reporting PolicySystems Thinking

Focus on harm and processes; not the care providerSafety Briefings with Employee FeedbackUnit Councils

Staff identify and address unit safety concernsInvolves staff in development of processes

CULTUREPHYSICIAN ENGAGEMENT

Patient Safety is a standing agenda item Safety Briefings and Feedback is providedMonthly updates of PI projects are providedRoot Causes Analyses include physician inputHuman Factors included in the Peer ReviewExpectations and goals of the organization are sharedEfforts made to obtain input while being mindful of the physician’s time

PHYSICIAN INPUTAd Hoc team developed process and protocol for Peri-operative Beta BlockadeAnesthesiologists developed Epidural ProtocolPediatricians requested child Med Safety Brochure for their officesInternists and CV Surgeons assisted in development of IV Insulin Infusion Protocol

CULTUREPATIENT INVOLVEMENT

Satisfaction survey questions for safetyMedication Safety Brochure given to all new admissions; distributed by physician offices Community resource collaboration to encourage patient to keep updated med listPatient education channel is available 24/7 with information about diseaseCommunity Board serves a dual role as the Patient Advisory Council

PATIENT SAFETY POSTERALSO AVAILABLE IN SPANISH

Be Involved in Your CareMake sure the nurse checks your armband before giving you your medicine.

Ask the nurse about medication that is unfamiliar to you BEFORE you take it.

Make sure the staff and physician washes their hands before / after providing care to you

MEDICATION RECONCILIATION

DefinitionA process of identifying the most accurate list of all medications a patient is taking and using this list to provide care in any settingIt requires comparing the patient’s list of current medications against the physician’s admission, transfer and discharge orders.

WHY DO THIS?Provides the ability to accurately compare home meds to meds ordered during hospitalizationDetects medication errors before they happenPromotes continuity of care between different levels of careWrong dose, route or frequency may be prescribedImportant meds may be omitted

RECONCILIATION PROCESSMed history is completedMed history is compared with admission medication ordersTransfer reconciliation is conducted when the patient moves to a different level of careDischarge reconciliation compares the meds ordered during hospitalization with those ordered to be taken at homeVariances between med history and admission orders is clarified with the physicianWhat is included?

Current home meds, OTC, HerbalsIncludes dose, route, frequency, time of last dose

WHERE TO GET INFORMATION

Patient or familyPatient’s pharmacyPrevious medical recordsPrimary care physician’s officePatient’s medication bottles

BARRIERSBureaucracyComplexity of communication--interruptionsAccountability—staff too busyLack of teamwork—office does not have updated list or nursing home list is confusingPatient brings in incorrect listPatient does not take what is marked on the bottlePatient does not know names of medsPatient is unable to tell you

ADMISSIONRECONCILIATION

OSF Healthcare System Performance Goals : SJMC : Pursuing Perfection In Safety : National Patient Safety-Admission Medication

Reconcilliation : By Month

0%10%20%30%40%50%60%70%80%90%

100%

[Oct-04 to Present : Inhouse Data Collection]

Percentage Rate

Go al Ad miss ion Reco nciliat io n 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% 10 0%

Ad miss ion Reco nciliat io n N 19 18 16 18 17 17 16 19

Ad miss ion Reco nciliat io n D 20 20 20 20 20 20 20 20

Rate Ad miss ion Reco nciliat io n 95% 9 0% 80% 9 0% 85% 8 5% 80% 9 5% 0% 0% 0% 0%

Oct-04

No v-04

Dec-04

Jan-0 5 Feb -05

Mar-05

Ap r-05

May-05

Jun-0 5 Jul-05 Aug-05

Sep -05

TRANSFER RECONCILIATIONOSF Healthcare System Performance Goals : SJMC : Pursuing

Perfection In Safety : National Patient Safety-Transfer Medication Reconcilliation : By Month

0%10%20%30%40%50%60%70%80%90%

100%

[Oct-04 to Present : Inhouse Data Collection]

Percentage Rate

Goal Trans fer Reconciliat ion 10 0% 10 0% 10 0% 10 0% 100 % 100 % 100 % 100 % 100 % 100% 100% 100%

Transfer Reconciliat ion N 5 7 7 6 6 8 8 5

Transfer Reconciliat ion D 10 10 10 10 10 10 10 10

Rate Trans fer Reconciliat ion 50% 70% 70% 60% 6 0% 8 0% 8 0% 50% 0% 0% 0% 0%

Oct-0 4

Nov-0 4

Dec-04

Jan-05 Feb -05

Mar-05

Apr-05

May-05

Jun-05 Jul-05 Aug-05

Sep-05

DISCHARGERECONCILIATION

OSF Healthcare System Performance Goals : SJMC : Pursuing Perfection In Safety : National Patient Safety-Discharge Medication

Reconcilliation : By Month

0%10%20%30%40%50%60%70%80%90%

100%

[Oct-04 to Present : Inhouse Data Collection]

Percentage Rate

Goal Discharg e Reco nciliat ion 10 0% 10 0 % 100 % 10 0 % 10 0% 10 0 % 10 0% 100 % 10 0% 100 % 10 0 % 100 %

Discharge Reco nciliat io n N 18 19 16 20 18 16 17 2 0

Discharge Reco nciliat io n D 19 19 18 20 19 18 2 0 2 0

Rate Discharg e Reco nciliat ion 9 5% 10 0 % 8 9 % 10 0 % 95% 8 9% 85% 100 % 0 % 0 % 0% 0 %

Oct-0 4

No v-04

Dec-0 4

Jan-0 5 Feb -0 5

Mar-0 5

Ap r-0 5

May-0 5

Jun-0 5 Jul-0 5 Aug-0 5

Sep-0 5

FMEA—DISPENSINGThe Dispensing FMEA has been reduced 66%Pharmacy reduced/standardized unit stock medsPharmacy prepares all non-standard doses

Labels on all IV pumps encourage caution when stopping the pump to make rate or dose changesIV Drug Administration Reference matrix directs dosages, guidelines, monitoring informationAn automated dispensing system was installed Renovation of nursing and pharmacy workspaces to improve process flow and efficiency

DISPENSING FMEAC Chart : IHI-ADE : Dispensing FMEA Chart

0

200

400

600

800

1000

1200

1400

1600

1800

[Jul-01 To Present : IHI-ADE Data]

Dispensing RPN

UCL=1230

Mean=1129

LCL=1028

Pharmacy O n Unit

Pharmacy Enters O rders

New Info System

FMEA-ORDERINGHazard Vulnerability Score has been reduced 34%A Periop-Beta Blocker Protocol was initiated 1/03Surgical Prophylaxis Antibiotic Protocol developedPharmacists assigned to a nursing unit/enter ordersRenal dosing review based on creatinine clearanceAbbreviations

Unapproved abbreviations are on orders sheetsIllegibility

Pharmacists call with any question of the orderRead-Backs

Nurses read back 95% of all telephone orders and sign with “TORB”

ORDERING FMEAC Chart : Ordering FMEA Chart

0

20

40

60

80

100

120

140

160

180

200

[O ct-02 To Present : IHI-ADE Data]

Hazard Vulnerability

Score

UCL=180

Mean=144

LCL=108

Pharmacy O n Units

Pharmacy Enters O rders

HIGH RISK MEDICATIONS

Heparin NomogramPCA Protocol with default ordersTPN ProtocolIV Insulin Infusion ProtocolChemotherapy Order SetCoumadin dosing serviceDVT ProtocolReview of all INR’s above 4 to identify opportunities in dosing regimens

SIMULATION

“Sim Man” purchasedSimulation lab createdSimulation used for Clinical Orientation for RN/LPN/US/CNASimulation used for annual skills validationSimulation used for Root Cause Analysis

ROOT CAUSE ANALYSIS

Human Factor Triage Questions incorporated into RCA—approved and applauded by JCAHOOne RCA resulted in improvements that prevented care issues in a subsequent trauma (ED/difficult intubation boxes)Success of RCA’s spreading—being used independently by other areas such as OR and EMS Services to evaluate a “near miss”

SBARSBAR Acronym-Situation, Background, Assessment and RecommendationLaminated pocket cards including the acronym have been distributed to all nursesPosters explaining SBAR have been posted in clinical areas and stickers have been placed on phonesUse of SBAR spreading to all areas for any issueMedical Staff are encouraged to ask staff to use SBAR

SBAR POCKET CARD

In the interest of Patient Safety and to ensure we are giving

complete, accurate information to the physician, please use the following acronym to direct the

information we provide:

S (the current Situation or problem)B (a little about the patient’s Background) A (your Assessment of the patient)R (your Recommendation of what is needed from the physician)

TEAM RESOURCE MANAGEMENT

Improves team efficiency and effectivenessIncludes multiple concepts

Communication tools—SBARStaff assertionSituational AwarenessBriefingsDebriefingsRed Flags

Initial and refresher training was provided to staff and physicians

BARRIERSLimited ResourcesLack of organization/leadership support Lack of physician buy-inResistance to changeStarting too bigMoving too quickReluctance to share safety concernsMultiple projectsAdded work instead of replacement

LESSONS LEARNED

Involve the right peopleUse rapid cycle tests of changeSimplify processesShare successesDon’t recreate the wheel—network with othersCommunicate

KEYS TO SUCCESS

Leadership SupportMake it a win-win situationReward and recognize staff Provide ongoing feedbackAlways make patient safety the priority!Never give up; there is no obstacle that cannot be overcome!!!

“Safety is like peeling an onion--the more you look, the more you find and each layer makes you cry”.