Enhanced Detection of Safety
Vulnerabilities in Kidney Transplantation
with
t a Web-Based
eb ased C
Clinician
c a Debriefing
eb e g
Lisa M
Li
M. McElroy,
M El
MD
T32 Postdoctoral Fellow, Northwestern University
Safety Vulnerabilities in Kidney Transplant
• Transplant
p
p
patients experience
p
high
g rates of adverse
events due to medical error
• Efforts to reduce the rates of medical errors in transplant
care have been in part stimulated by high
high-profile
profile adverse
events
Reporting Safety Vulnerabilities
Incident Reporting Systems
Submitted by front-line personnel
Highlight specific incidents
Confidential or anonymous
Focused on adverse events
Under utilized by physicians
Voluntary; subject to selection bias
Reporting Safety Vulnerabilities
Incident Reporting Systems
Submitted by front-line personnel
Highlight specific incidents
Confidential or anonymous
Focused on adverse events
Voluntary; subject to selection bias
Under utilized by physicians
Evans SM. Qual Saf Health Care. 2006;15:39; Levtzion-Korach O Jt Comm J Qual Patient Saf. 2010;36:402.
Reporting Safety Vulnerabilities
Clinician Debriefings
g
• Proactive
– Active solicitation independent of adverse events
•
Reporting of perceived hazards, errors and near misses
encouraged in addition to adverse events
•
Used as complement to incident reporting
– Adverse drug events
– Critical care
– Pediatrics
Benn J. Q
Qual Saf Health Care. Feb 2009;18(1):11-21;
( )
Chrysant
y
SG. The Journal of Clinical Hypertension.
yp
2008;10(9):716-722;
( )
van Beuzekom M. Qual Saf Health Care. Feb 2007;16(1):45-50; Slonim AD. Pediatrics. Mar 2003;111(3):617-621;
Transplant Safety Debriefing
Please report ALL issues, problems, barriers or annoyances you experienced or
witnessed,
i
d even if they
h are minor
i
and
d did not impact
i
the
h patient
i
(near
(
miss).
i )
Did you follow up on issues described in this debriefing? How?
Did you have suggestions to address the issues described in this debriefing?
How would you improve patient safety?
Study Design
Studyy Objective:
j
To assess the abilityy of a p
proactive,, webbased clinician safety debriefing to increase information
about safety vulnerabilities.
– Increased reporting before harm suffered by patients
– Increased physician reporting
• Study Period: April 1, 2010 – April1, 2011
• Population: Adult kidney transplant donors and recipients
Methods
1. Requests
q
to complete
p
the web-based debriefingg
emailed to individuals listed on operating room
personnel reports immediately following surgery.
– Reminders to non-responders at 24 hours
Debriefings requested after each surgery
April 1 2010
April 1 2011
Methods
1. Requests
q
to complete
p
the web-based debriefingg
emailed to individuals listed on operating room
personnel reports immediately following surgery.
2. Incident reports were obtained for all kidney transplant
donors and recipients via report from hospital Risk
Management.
Debriefings collected after each surgery
April 1 2010
Incident
reports
collected
April 1 2011
Methods
1. Requests
q
to complete
p
the web-based debriefingg
emailed to individuals listed on operating room
personnel reports immediately following surgery.
2. Incident reports were obtained for all kidney transplant
donors and recipients via report from hospital Risk
Management.
3. Information from both collection methods reviewed and
classified.
Debriefings collected after each surgery
April 1 2010
Incident
reports
collected
April 1 2011
Data
analysis
Data Analysis
y
• Safety issue identification
within reports
• Issue classification using
the WHO International
Cl ifi ti ffor P
Classification
Patient
ti t
Safety
– Safety
S f t Incident
I id t
• Severity
• Subject
– Contributing Factors
Patient Characteristics
Age –Mean ± SD
Male Gender
Race/Ethnicity
Non-Hispanic White
Non-Hispanic Black
Hispanic
Asian
Primary Language
English
Spanish
Other
Insurance
Medicare
Private
Medicaid/Self-Pay
Kidney Donor
All Patients
(N=467)
47.1±13.7
239 (51.2)
Debriefings
(N=325)
47.5 ± 13.7
163 (50.2)
Incident reports
(N=47)
49.5 ±14.3
22 (47.8)
249 (53.3)
107 (22.9)
83 (17.8)
17 (3.6)
174 (53.5)
78 (24.0)
53 (16.3)
13 (4.0)
27 (52.2)
12 (26.1)
6 (13.0)
2 (4.4)
434 (92.9)
31 (6.6)
2 (0.4)
297 (91.4)
13 (4.0)
15 (4.6)
43 (91.3)
2 (4.3)
2 (4.3)
147 (31.4)
111 (23.7)
209 (44.7)
190 (40.6)
80 (24.6)
11 (3.4)
234 (72.0)
151 (46.5)
16 (34.8)
3 (6.5)
27 (58.7)
19 (41.3)
Debriefing and Incident Report Responses
Reports submitted
Respondents
Nurses
Physicians
Other
Total Issues reported
Patient Safety Incidents
Contributing Factors
Mitigating Factors
Debriefings
N (%)
270
Incident Reports
N (%)
57
106 (39.2)
112 (41.4)
52 (19.3)
383
179 (range 0-7)
155 (range 0-5)
0 5)
49 (range 0-3)
44 (77.2)
2 (3.5)
11 (19.3)
92
56 (range 0-1)
36 (range 0-2)
0 2)
0
Patient Safety Incident Severity
D b i fi
Debriefings
(N
(N=179)
179)
Adverse
Events
17%
Near Miss
16%
Incident Reports (N=56)
Adverse Events
23%
Reportable
Circumstances
6
67%
Reportable
Circumstances
27%
Near Miss 50%
Patient Safety Incident Topics
0.30
Perccent of To
otal
0.25
0.20
0.15
0.10
0.05
0.00
Debriefings
I id
Incident
R
Reports
Incident Report Example:
Medical Device/Equipment
“During
“D
i g the
th laparoscopic
l
i donor
d
nephrectomy,
h t
on the
th
initial fire of the stapler on the first renal artery, the
stapler fired but did not cut.
cut ”
Clinician Debriefing Example:
Medical Device/Equipment
“The
The whole sterile table had to
be broken down and set back
up because of what appeared to
be a break in sterility. This
delayed the start time. However
I have to say the surgeon was
very understanding. The tray
was sent to the supply manager
and the problem was
di
discussed.”
d”
Limitations
• Pilot implementation
p
completely
p
y anonymous
y
– Limited ability to track response rate, provide feedback
• Persistent risk of selection bias
• Narrow patient population
– Recent implementation in colorectal surgery
Conclusions
• Clinician debriefings
g can augment
g
traditional incident
reporting systems in the assessment of the safety
vulnerabilities in complex surgical care.
• Debriefings demonstrated multiple advantages:
- Increased information
- Increased focus on contributing and mitigating factors
- Increased participation by physicians
• Medical device/equipment malfunction,
resources/organizational are newly identified safety
vulnerabilities
l
biliti iin kid
kidney ttransplantation
l t ti
THANK YOU
Acknowledgements:
A. Daud, B. Lapin, A.I. Skaro, D.M. Woods, J.L. Holl, D.P. Ladner
Northwestern Medicine Institutional Dixon Translational Grant
AHRQ and NIDDK T32 Training Grants