Never Events Board Presentation
Lisa Beckman, Connie Egerer, Kerry Heinecke
Med Inf 404, Spring 2010
Hospital Background
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Mid-State University Medical Center is a large midwestern university hospital complex
Adult patient hospital is an 11-story, 550-bed, 1.8
Million sq. ft. hospital, opened in 1986
Children’s hospital is a 9-story, 350-bed, 700,000
sq. ft. hospital opened in 2008
Each house diagnostic equipment, clinical
laboratories, operating rooms and inpatient and
intensive care units
70 percent of patients are admitted from other
communities or regional hospitals
Never Events Background
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IOM Reports raised awareness of medical errors
CMS lists 17 never events which are nonreimbursable hospital acquired conditions
NQF Serious Reportable Event (SRE) list covers 28
types of events grouped in 6 categories
Purpose of the SRE’s is to facilitate public
accountability for occurrence of medical errors.
No federal law mandating reporting; many states
have enacted laws requiring reporting of SREs
Mid-State University
Medical Center
Serious Reportable Events
Quality Initiative Progress
and Recommendations
Presenters
• Lisa Beckman, Chief Executive Officer
• Connie Egerer, Chief Quality and Safety
Officer
• Kerry Heinecke, Director of Risk
Management
5/24/2010
Board Meeting
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Agenda
• Key Objectives
• SRE Dashboard
• 2008 / 2009 Results for NQF Serious Reportable
Events (SRE’s)
• Comparison to Similar Institutions
• Pareto Analysis
• Example SRE
• Recommendations
• Conclusion
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Key Objectives
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Safe
Patient Centered
Effective
Efficient
Timely
Equitable
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2010 Dashboard Key SRE’s
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Serious Reportable Events
16
14
12
10
8
6
4
2
0
5/24/2010
2008
2009
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Breakdown of Category
Product / Device SRE's
1
1
Contaminated drugs,
devices, or biologics
Device use or function
other than intended
Intravascular Air
Embolism
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Serious Reportable Events
16
14
12
10
8
6
4
2
0
2008
2009
2009 Similar
Institutions
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Pareto Analysis
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2009 %
2009 Cum %
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Device Event Example
Place Film
Plate
Take x-ray
FILM
Move x-ray
machine away
Retrieve Film
Plate
Place
Tethered Plate
Take x-ray
DR
Retrieve
Tethered Plate
Move x-ray
machine away
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Device Event Example
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November 2009
Relatively new x-ray technology
Experienced x-ray tech
Dispatched to PICU for portable x-ray on 2 week old
infant POD 1 from open heart surgery to repair complex
Congenital Heart Defect
– Intubated
– Open sternum
– Multiple chest tubes,
– IV’s, intracardiac lines
– Dopamine/Epi to
maintain BP
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SRE Event detail
Place
Tethered Plate
Take x-ray
Physician
requests to
view
Retrieve
Tethered Plate
Move x-ray
machine away
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Consequences
– Extubated – required reintubation
– Skeletal series & cranial Ultrasound
to Rule Out injury
– Family distress
– Caregiver distress
– No obvious sustained injury
– Hospital absorbed extra cost
– Hospital paid for family’s meals
and lodging in Hotel
– $100,000 detector plate shattered
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Potential Consequences
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–
–
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Severe injury or disability
Prolonged hospitalization
Death
Even more severe family and caregiver
distress
– Publicity/damage to reputation
– Lawsuit
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Root cause analysis
– This was still a new processdetector/(plate) now tethered
to machine with cable
– Tech was distracted and
reverted back to old habit of
pulling machine away quickly
– Near misses not taken
seriously enough
– RN and RT not “engaged” in xray taking process – distracted
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IMPROVEMENT PRINCIPLES
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The safest thing to do is the easiest thing to do
Reduce reliance on memory
Use fail-safe systems and forcing functions
Standardize and simplify processes
Design systems to be resistant to psychological
and environmental precursors to error – reduce
stress in the environment
• Enhance access to complete & timely
information
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How did we fix this?
– Met with product rep to discuss safety issue
• Sensor added to the storage slot for the detector
• Activates switch when in detector in place
• Switch must be active to move backwards (i.e. plate
must be in place, otherwise machine in very slow mode)
– 3 “Must do’s” with EVERY portable x-ray
• MUST have second assist with plate/detector
removal (RN, RT, MD, Tech)
• MUST state out loud “Are we ready to remove the
detector?”
• MUST have OK from second assist: “Lines and
tubes secure. It’s OK to remove the detector.”
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How did we fix this?
– Retraining of all techs
• Must pass competency in
Simulation center
• Emphasized 3 “Must do’s”
• 2 techs together for portables for the next 3 weeks
– Chief safety officer sent memo to all clinicians
and managers:
• “Do Not Distract X- Ray Technician”
• 3 “Must do’s” with EVERY portable x-ray
– Near miss log
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How do we prevent SRE’s?
We can benefit from lessons learned from the adoption of
an EMR by recognizing the following:
– The hospital is becoming a more and more complex
environment
– New errors result from the use of complex technology
in a very complex work environment
– Anticipate the unintended and actively look for
problems
– End users must be encouraged to report problems
found, including near misses
SRE’s
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Evaluation
• Who are the customers
– External
– Internal
• What is important to them
• How do we measure what is important
• How are we doing
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Recommendations
• Continue to promote safety culture
• Safety champions throughout the
hospital
• Develop internal web page for
equipment/technology safety issues
– Staff can easily submit information
• Near misses
• New ideas
• Safety issues in general
– Reward staff for good ideas
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Recommendations
• Form committee to evaluate new
product or device use
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Quality and Safety officer
Unit/department Managers
Key unit educators
Vendor rep
Must include users from all
relevant departments
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Recommendations
• Committee Agenda:
 HLPM of current process
 HLPM of new process
 Highlight significant differences
 Encourage end users to “Anticipate the
unintended and actively look for problems”
– Consider use of a Simulation Center for training
– Establish check-off requirements
– Consider use of a buddy system for high-risk
procedures for defined training period
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Resources Required
• Staff release time for committee work
– Membership of committee changes
with each new product/device introduced
– Requires back-up coverage
– Staff time to complete the analysis and to
develop new procedures and training
• Staff time for training
• Developer time for web page
• Vendor contracts to include participation
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Resources Required
• Clinical Simulation Center – use existing
equipment for training
– SimMan
– PediaSim
– Neonatal simulator
• Consultation with Simulation Center
Training Staff
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Conclusion
• Safety focus program on SRE’s has been
successful in reducing numbers of surgical
events
• Current priority is reduction of Product or
Device SRE’s
• Questions
5/24/2010
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References
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https://courses.northwestern.edu/
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Executive Office of Health and Human Services. (2009). Serious reportable events in Massachusetts acute care hospitals: January 1, 2008 – December 31,
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General Electric Company. (2007). AMX-4+ mobile x-ray system [PDF Document]. Retrieved from
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b30210VgnVCM10000024dd1403
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http://books.nap.edu/openbook.php?record_id=10027&page=R1
Kizer, K. W. & Stegun, M. B. (2005). Serious reportable adverse events. Advances in patient safety (4). Retrieved from
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.7695
National Quality Forum (NQF). (2006). National quality forum updates endorsement of serious reportable events in healthcare. Retrieved from
http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf
Patterson, E. S., Cook R.I., & Render M.L. (2002, Sep-Oct). Improving patient safety by identifying side effects from introducing bar coding in medication
administration. Journal of the American Medical Informatics Association, 9 (5), 540-53.
University of Michigan Health Center. (2008). Clinical simulation center. Retrieved from http://www.med.umich.edu/umcsc/index.html
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