Mary Reich Cooper, M.D., J.D.
Senior Vice President and Chief Quality Officer, Lifespan
Asst. Professor, Medicine,
Alpert Medical School of Brown University
February 5, 2011

My first deposition: I was not yet a J.D.

Agenda:
Institute of Medicine Approach to Quality
SAFE
IOM 2001
Crossing the Quality Chasm

Safe Care: The Past Decade
 Safety Surveys
 Safety Culture
 Safety Rounds
 Crew Resource
Management
 Team Training
 Just Culture
 Medical
Errors/Adverse Events
 Near Misses & Good
Catches
 Unsafe Conditions
 RCAs
 FMEAs
 PSOs

Event # 1
You are the doctor in charge.

Monday 11 am
You are in the
OR
Your P.A. is in the ED
Condition deteriorates
81 yo M comes into
ED
Patient transferred to
OR

Event Occurs
Responsibility,
Accountability,
Culpability?

RIH Events: 2004 -2011
 2007
 January: wrong side neurosurgical drainage of subdural hematoma bedside
 July: wrong-side drainage of subdural hematoma operating room main
 November: wrong side neurosurgical drainage of subdural hematoma bedside
 2009
 May: wrong-side palate children’s operating room
 October: wrong site finger ambulatory operating room

Rhode Island Hospital
Surgery Cases

Surgery Errors/100,000 Patient Days
Statewide Wrong Site Errors/100,000 Pt Days*
RI, MA, and MN
1.2
1
1.6
1.4
0.4
0.2
0.8
0.6
0.2961
0.7402
0.7403
1.361
0
RI-1 (FY2008) RI-2 (CY2009) MA (FY2008) MN (CY2008)
*Source: MA and MN from annual statewide reporting based on NQF SRE's. Includes surgical events on the wrong body part, the wrong patient, and the wrong procedure. Excludes surgical events for foreign objects and intra/post surgical deaths. MA data from FY2008; MN data from CY2008. RI data from Projo article, "Another wrong-site surgery at Rhode Island Hospital" by Felice Freyer Saturday
Oct. 24th, 2009. RI-1 rate based on FY2008 count of 2 (Nov 23, 2007 and Sept 19, 2008). RI-2 rate based on CY2009 count of 5 (1 at RIH in May, 2009; 2 at Kent in June, 2009; 1 at TMH in June,
2009; 1 at RIH in Oct, 2009) with FY2008 patient days (patient days for CY2009 not available).

The National Experience

Source: Seiden S, Barach P. Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events. http://archsurg.ama-assn.org/cgi/content/full/141/9/931 . Acessed
October 27, 2009.

Massachusetts
Department of Public
Health Adverse Event Reporting
HOSPITAL
TOTAL
MASS GENERAL HOSPITAL
BETH ISRAEL DEACONESS MED CTR/EAST
BOSTON MED CTR CORP MENINO PAVILION
UMASS MEMORIAL
ST VINCENT HOSPITAL
BAYSTATE MEDICAL CENTER
BRIGHAM & WOMEN'S HOSPITAL
3
3
0
0
0
1
1
0
0
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
1
1
4
3
4
1
2
0
0
Source: Commonwealth of Massachusetts Department of Public Health 2008 Report: Serious Reportable Events in Massachusetts Acute Care Hospitals http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/sre_acute_care_hospitals.pdf
4
4
4
3
3
3
3

Massachusetts
Department of Public
Health Adverse Event Reporting
HOSPITAL
MASS GENERAL HOSPITAL
BRIGHAM & WOMEN'S HOSPITAL
BAYSTATE MEDICAL CENTER
BETH ISRAEL DEACONESS MED CTR
JORDAN HOSPITAL
TUFTS MEDICAL CENTER
3
2
2
1
1
1
1
0
0
1
1
0
6
3
2
2
2
3
TOTAL
10
5
4
4
4
4
Source: Commonwealth of Massachusetts Department of Public Health 2009 Report: Serious Reportable Events in Massachusetts Acute Care Hospitals http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/sre_report_2009.pdf

Connecticut
Department of
Public Health Adverse Event
Reporting
All Hospitals
2005
2006
4
3
3
0
1
2
2
0
4 2007
2008 5 0 1 14
Total 15 3 7
Source: Connecticut Department of Public Health Legislative Report to the General Assembly: Adverse Event Reporting October 2008 http://www.ct.gov/dph/lib/dph/government_relations/2008_reports/oct2008_adverseeventreport_finaldraft.pdf
68
19
18
17
0
0
1
0
1

Briefing Required
• Surgeon identifies patient, procedure, site/side mark, (confirmed with consent by
RN) and discusses the plan for surgery
• Identify new team member(s) and role
•
Discussion Points (as applicable):
Antibiotic status
- Glycemic control
- Beta-blockers
- Medications needed on field/irrigation
- Patient position
- Equipment/implants required for procedure
- Patient safety considerations
- Blood
- DVT prophylaxis
- Allergies
- Special considerations (hearing deficit, language barrier, friable skin, risk for pressure ulcer, pacemaker, etc.)
- X-rays/PACS up on screen
- Lab work
- Consult(s)
•
Does anyone have any concerns?
• Surgeon asks are we ready to begin?
Time Out Required Debriefing Required
• Initiated by attending surgeon
• Patient identification, procedure site/side (confirmed with consent by
RN through read back)
• Initiated by attending surgeon prior to leaving the Operating
Room
• S pecimen labeling and destination communicated
• Surgeon’s initials (if applicable ) on procedure site/side visible after prepping and draping
• Confirmation by team that the mark (If applicable) is visible
• Confirmation of procedure performed
• Does anyone have any concerns?
• Are we ready to proceed?
•
Discussion Points ( as applicable):
Post-op plan of care (ICU bed, ventilator, etc.)
- Patient temperature
- Wound classification
- Review of what worked well and what could have been done differently
- Identify any instrument/ equipment concerns
Revised 06/18/10

Wrong Site Surgery – Are They Preventable?




Wrong-side/wrong-site , and wrong patient adverse events
(WSPE) are more common than previously reported. Based on the several available databases these adverse events have been occurring steadily for years without significant attention or evidence of reduction in prevalence.
The data support widespread underreporting of these adverse events.
At a minimum, assuming 100% of cases are reported, our extrapolation of data from Florida predict that there would be
1321 cases in the United States annually.
However, multiple studies have demonstrated that the compliance of physicians in reporting has ranged from 5% to
50% of events thus predicting a WSPE events in the United States annually.
incidence of 2600
Source: Seiden S, Barach P. Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events. http://archsurg.ama-assn.org/cgi/content/full/141/9/931 . Acessed October 27, 2009.
Arch Surg 2006;141;931-9

Event # 2
You are the doctor in training.

Wednesday 2 am
You are covering
Radiology at night
You stop the
MRI
The tech has noticed an artifact
The patient had surgery earlier that day
You confer with the surgical resident

Event Occurs
Responsibility,
Accountability,
Culpability?

Minnesota Experience
Source: Minnesota Department of Health: Adverse Health Care Events Reporting System: What have we learned? 5-year REVIEW (2003-2008) http://www.health.state.mn.us/patientsafety/publications/2010ahe.pdf

Mandated Reporting: http://www.jointcommission.org/sentinel-event-statistics/ accessed 1/14/2011

Medicare Says It Won’t Cover Hospital Errors
•
Sign In to E-Mail or Save This
By ROBERT PEAR
Published: August 19, 2007
WASHINGTON, Aug. 18 — In a significant policy change,
Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars…..

HAC: Preventable Complications
1. Object left in surgery
2. Air embolism
3. Blood incompatibility
4. Catheter Associated Urinary Tract Infection
5. Pressure Ulcers
6. Catheter Associated Blood Stream Infection
7. Surgical Site Infection – Mediastinitis; Orthopedic;
Bariatric
8.
9.
10.
Injuries
Glycemic Control (Blood Sugar)
DVT (Clots)

Event # 3
You are the medical student.

Saturday 2 pm
Admission to your unit:
76 yo F
Your resident is putting in a line
You are asked to do admit
H&P
Your patient has been in the
ED for 12 hours
Everyone is in a hurry to start treatment

You see this….

Event Occurs
Responsibility,
Accountability,
Culpability?

Why Is This Picture Important?
Stage I Pressure Ulcer
(Bed Sore)

Why are Pressure Ulcers Important?
 The annual cost for treating pressure ulcers in the
US ranges between 2.2 and 3.6 Billion dollars
 Rhode Island begins public reporting on hospitalacquired pressure ulcer assessments in 2009
 CMS stopped paying hospitals for Stage 3 and 4 hospital-acquired pressure ulcers in October 2008
 Over the past 10 years, we have paid out 1.5 million dollars in claims brought for patients who developed pressure ulcers


NDNQI requires pressure ulcer reporting
Pressure ulcers are no longer “nursing” indicators

Event # 4
You are a doctor on the team.

Wednesday 7 pm
You are eating dinner
The nurse tells you your patient has pain
You order
Morphine 5 mg
The patient stops breathing
You reverse it with Naloxone

Event Occurs
Responsibility,
Accountability,
Culpability?

On a given day at Lifespan Hospitals…
 85 medication errors (actual and prevented) will be reported
 39 actual medication errors will be detected and reported
 46 medication errors will be prevented
 MAK will prevent…
 6 “Wrong patient” medication related errors (bring up a patient record and scan the patient’s bracelet, not a match)
 6 “Wrong drug,” Wrong dose,” “Wrong route” errors (have correct patient record that matches the patient’s bracelet, but scan of medication reveals drug error)
 30 prescribing errors will be prevented
 5 excessive doses of medication will not be given

1 drug allergy will be avoided

Innovation
Electronic Medical
Records

Innovation
Smart Pumps

Innovation
Patient
Identification

Event # 5
You are a doctor on the team.

Tuesday 10 am
You are on rounds
The patient spikes a fever
Your attending asks you to talk about BSI
Sentinel
Event?
The patient has a SC catheter

Event Occurs
Responsibility,
Accountability,
Culpability?

National Healthcare Safety
Network (NHSN)

Rhode Island ICU Collaborative
ICU Collaborative Lifespan Performance- Comparative Data - 2006-quarter 2 2010
BSI (goal is zero) - infections/1000 line days* VAP (goal is zero) - infections/1000 vent days* VAP Bundle Composite
(goal is >90%- higher is better)
Lifespan - ICU
Newport Hospital ICU
Rhode Island Hospital ICCU
2006 2007 2008 2009
0.00
0.00
0.00
0.00
%chg 06-
09
0.00%
0.00
0.00
0.00
3.23
0.00%
3.01
1.15
1.03
0.53
-82.39%
Q1
2010
Q2
2010
0.00
0.00
Q3
2010
Q4
2010
2.89
0.00
0.00
0.00
0.00
0.00
0.00
Rhode Island Hospital 5ISCU
Rhode Island Hospital CCU
1.96
0.00
0.00
0.00
-100.00%
1.48
0.00
1.94
2.54
71.62%
0.00
0.00
0.00
0.00
0.00
0.00
Rhode Island Hospital CTIC
Rhode Island Hospital ICTU
6.41
0.00
2.10
0.00
-100.00%
1.78
1.46
0.85
0.48
-73.03%
0.00
0.00
0.00
1.82
5.38
0.00
Rhode Island Hospital INC
Rhode Island Hospital MICU
1.96
1.66
1.00
1.51
-22.96% 3.25
2.18
2.69
Rhode Island Hospital RICU
Rhode Island Hospital SICU
3.39
1.84
1.50
0.80
-76.40%
4.79
1.34
1.97
1.59
-66.81%
0.00
2.16
4.96
2.00
0.00
0.00
Rhode Island Hospital TICU
Miriam Hospital CCU
Miriam Hospital CVTI
Miriam Hospital CVTS
Miriam Hospital ICU
Statewide Aggreggate
Mean
Statewide Aggreggate
Median
Aggregate numerator/demominator
4.49
2.22
5.83
4.90
0.00
2.24
0.00
0.00
9.13%
0.00
0.00
0.00
0.00
0.00
0.00
3.76
1.03
1.24
0.69
-81.65%
4.00
2.99
1.16
1.06
-73.50%
3.12
1.80
1.69
1.64
-47.44%
2.41
1.34
1.24
1.34
-44.40%
0.00
6.36
3.95
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.27
1.67
1.49
0.00
0.00
0.00
116/
37266 36213 37337
64/
39049
12/
9475
2.90
1.56
1.37
1.25
-56.90% 0.77
15/
9006
13/
8706
1.58
1.72
Lifespan Aggregate mean
Lifespan Aggregate numerator/demominator
72/
24860 24332 25499 26322
5/
6514
2.96
1.46
1.56
1.46
-50.68% 1.02
17154 18643
28/
19234
10/
6349
10/
5798
2.19
1.95
RIH Aggregate mean
RIH Aggregate numerator/demominator
52/
17539
5/
4899
10/
4556
8/
4112
TMH aggregate mean
3.36
2.06
1.90
0.72
-78.57% 0 0.00
TMH Aggregate numerator/demominator
21/
6252 6307 6445
5/
6930
* BSI and VAP definition changed to NHSN as of 1/1/09 (previously NNIS)
** No data submitted
***No data available(little to no vents)
KEY - 2006-2009 comparison:
RED BOX=performance decline
GREEN BOX=improved or same
0/
1419
BSI - 86% (13/15 units) improved or stayed at zero, 2006 compared to 2009.
VAP - 54% (6/11 units) improved or stayed at zero, 2006 compared to 2009
VAP Bundle - 100% (11/11) improved and 73% (8/11) met goal of >90% compliance
0/
1521
1/
0.75
1340
0.67
6.08
7.86
2.87
11.98
9.71
11.20
4.01
2006
4.48
2007 2008 2009
2.90
1.76
4.85
%chg 06-
09
8.26%
0.00
0.00
0.00
0.00
0.00 0***
0.00 0***
0.00%
0.00%
0.00
0.67
0.00
7.65
0.94
1.63
2.47
0.00
2.36
0.30
0.00
2.39
0.00 0***
11.45
0.63
2.05 205.00%
3.24 383.58%
10.96
0.00
43.27%
2.19 132.98%
1.71
4.50
1.61
7.31
3.29 391.04%
5.61
8.50
7.44
7.14
-7.73%
-9.16%
4.10
7.30
0.00 -100.00%
0.00
0.00 0*** -100.00%
4.13
12.92
14.68
51.18%
6.71
2.99
2.50
-77.68%
3.36
3.28
3.40
-15.21%
2.34
2.47
1.61
2.27
-2.99%
Q1
2010
0.00
Q2
2010
Q3
2010
0.00 17.39
Q4
2010
2006 2007 2008 2009
%chg 06-
09
76.26
93.96
99.10
96.86
27.01%
0.00
0.00
0.00
0.00
0.00
0.00
***0
***0
***0
***0
***0
***0
***0 N/A
***0 N/A
0.00
0.00
0.00
0.00
0.00
4.33
0.00
0.00
0.00
7.17
4.33
6.51
1.13
1.25
2.87
17.14
38.55
75.32
75.73 341.83%
72.12
24.00
80.62
90.29
25.19%
***0 ***0 *** ***0 N/A
27.15
18.60
86.28
91.08 235.47%
73.95
52.41
62.10
79.96
8.13%
3.09
3.05
6.92
7.37
4.80
2.83
14.55
9.33 13.38
0.00 21.28
0.00
0.00
0.00
0.00
0.00
0.00
6.90
1.79
0.00
2.06
2.91 *2.19
4.90
71.34
47.58
67.26
94.89
33.01%
56.67
72.29
87.40
94.91
67.48%
64.26
50.44
80.38
88.70
38.03%
43.05
67.40
97.44
92.91 115.82%
98.46 100.00 100.00 ***0 N/A
76.68
72.69
98.95
97.12
26.66%
49.31
71.81
98.30
95.43
93.53%
61.64
69.21
79.99
87.26
41.56%
0.00 0*
29625
4.67
99/ 89/
29428 27122
3.33
4.03
91/
26765
4.26
-8.78%
18/
6180
3.91
92/
19702
3.14
62/
18637
68/
16864
72/
16902
16/
4095
2.76
3.87
4.26
35.67% 4.56
46/
14634
10.06
40/
14491
51/
13195
56/
13147
15/
3293
5.79
5.16
4.15
-58.75% 1.53
42/
4175
20/
3457
16/
3101
13/
3136
1/
655
2.83
14/
5923*
29/
5918
2.74
6.21
11/
4014
24/
3866
3.09
6.06
10/
3238
18/
2971
1.57
3.17
1/
635
2/
631
KEY - 2006-2009 comparison updates:
AQUA BOX=zero infections for 12 consecutive months
YELLOW BOX=zero infection for 24 consecutive months
LT GREEN BOX=zero infection for 36 consecutive months
PINK BOX=zero infection for 48 consecutive months
PURPLE BOX=90% composite goal met
67.41
70.55
87.4
90.63
34.45%
7016/
11386
9337/
13422
10913/
13637
13380/
15333
63.13
62.73
81.33
91.06
44.24%
3149/
4988
4064/
6479
5995/
7371
7647/
8398
64.04
51.31
72.87
88.92
38.85%
1136/
1774
1874/
3652
3601/
4942
5162/
5805%
63.76%
58.33
71.73
1425/
2443
1505/
2098
98.4
1845/
1873
95.52
1898/
1987
Q1
2010
Q2
2010
Q3
2010
99.28 99.28 92.69
0.00
0.00
0.00
0.00
0.00
0.00
85.45 85.45 100
96.8
96.8 97.87
0.00
0.00
0.00
93.22 93.22 94.03
68.33 68.33 98.05
93.97 93.97 100
98.83 98.83 92.75
95.26 95.26 93.66
100.00 96.77 93.75
0.00
100
96.67
96.3 96.1
99.7 98.49 99.6
86.45
92.23 87.44
93.97
2942/
3403
96.3 93.75
2599/ 2290/
2818 2619
91.73
95.81
96.43
1631/
1778
1325/
1383
1162/
1205
88.59 94.43 96.58
1118/
1262
830/
879
622/
644
99.47 98.02 98.54
376/
378
346/
353
337/
342
Q4
2010

Safety is our highest priority

Where are we now?
 169separate measures
 33 core
 Measures cover 5 main dimensions of quality
 Effectiveness
 Patient Safety
 Timeliness
 Patient Centeredness
 Efficiency
2009 National Healthcare
Quality Report

Highlights
 Health care quality is suboptimal and continues to improve at a slow pace
 Process measures are improving more rapidly than outcome measures
 Health care quality measurement is evolving, but much work remains

Trend in Quality Measures
 Median annual rate of change for the 33 core measures = 2%
 Treatment measures improving more rapidly than preventive or chronic measures
National Quality Report 2009:
AHRQ

Patient Safety is Lagging
 Safety rate of improvement is ½ rate of quality improvement
 But, better than last year
2009 AHRQ Quality Report

Rhode Island Quality
Rhode Island
Dashboard on Health Care Quality Compared to All States
Overall Health Care Quality http://statesnapshots.ahrq.gov/snaps08/dashboard.jsp?menuId=4
&state=RI&level=0 accessed on 1/14/2011

Rhode Island Quality http://statesnapshots.ahrq.gov/snaps08/dashboard.jsp?menuId=4&state
=RI accessed 1/14/2011

“Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.”
—James Reason

• Open atmosphere for reporting and addressing safety risks
• Careful monitoring and timely re-design of internal patient care systems
• Commitment to the highest possible standards of personal and collective accountability , integrity , and professional behavior

Leape (2009)

68% of hospitals do not have established environments that support reporting
Farley, D.O., Haviland, A., Champagne, S., et al.
Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf
Health Care, 17|6|:416-23, December 2008

National Benchmarking Organizations
NACHRI

What didn’t I cover?
Measurement
Patient Centered Care
Equitable Care
Innovation and
Research
Efficiency, Effectiveness

What Not To Do http://www.youtube.com/wa tch?v=LhQGzeiYS_Q

MCOOPER@LIFESPAN.ORG
...