Sara Albolino, PHD, CRMRiccardo Tartaglia, MD, Eur-Ergwww.regione.toscana.it/rischioclinicorischio.clinico@regione.toscana.it

Apply patient safety solutions to clinical practice. Why is it so

hard?

ALIAS Conference 14-15 June 2012, Florence (Italy)

A SESAR Innovation Challenge:Responsibilities, Liabilities and Automation in

Aviation

Differences in safety and reliability

Bagnara, Parlangeli, Tartaglia. Applied ergonomics, 2010

Risk perception

Unsafe climate5.6% naval aviators vs 17.5% healthcare operators (20.9% in emergency department and operating room) Gaba et al., 2003

vs

Emotional involvementThe technology barrier is thin

Direct relationship between the doctor and the patient“double human being systems”

Amalberti, R. et. al. Ann Intern Med 2005;142:756-764

The barriers to ultrasafe

When compared with traditional HROs, hospitals are undoubtedly high-risk organizations, but have

specificities and experience systemic socio-organizational barriers that make them difficult to transform into HROs

Bagnara, Parlangeli, Tartaglia. Applied ergonomics, 2010

Outline

• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and

implications for the future

Outline

• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and

implications for the future

The starting point

Incidence of adverse events (1964-2010)

Eight studies including a total of 74 485 patientrecords were selected. The median overall incidence of inhospital adverse events was 9.2%, with a medianpercentage of preventability of 43.5%. More than half(56.3%) of patients experienced no or minor disability,whereas 7.4% of events were lethal. Operation- (39.6%)and medication-related (15.1%) events constituted themajority.

First conclusions (2008)

Adverse events in developing countries

Of the 15 548 records reviewed, 8.2% showed at least one

adverse event, with a range of 2.5% to 18.4% per country.

Italy Tartaglia quality 7573 5,17 56,7

Adverse events in Italy (2011)

Tuscany teaching hospitals

Tartaglia quality 4227 6,7 42,9

Community hospitals

Tartaglia quality 7066 1,9 56,8

600.000 patients experience an adverse events every year

Outline

• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and

implications for the future

Advancing the science of patient safety.Shekelle PG, Pronovost PJ, Wachter RM et Al.Ann Intern Med. 2011 May 17;154(10):693-6.

• Despite a decade's worth of effort, patient safety has improved slowly

• Complexity of the interventions and diversity of the contexts matter

Improving slowly

The impact of the context

What context features might be important determinants of the effectiveness of patient safetynpractice interventions?Peter J Pronovost, John Øvretveit, BMJ Qual Saf 2011

A framework for classifying patient safety practices: results from an expert consensus process Peter J Pronovost, John Øvretveit, BMJ Qual Saf 2011

A framework for classifying patient safety practices

Advancing the science of patient safety.Shekelle PG, Pronovost PJ, Wachter RM et Al.Ann Intern Med. 2011 May 17;154(10):693-6.

Evaluation of the impact of this characteristics is important:• To help organization judge wheter an intervention

shown to be effective elsewhere is likely to work in their settings

• To propose cointerventions that can support implementation of a given practice

• To evaluate if the costs of an intervention may outweigh its benefits

Improving slowly

The impact of the patient safety culture

More of 70% professionals declared to have experienced an adverse events but half of them did not report them because:•It is not a priority•Fear of mistrust among colleagues•There is not a reporting culture in my organization

Randomized sample of 942 healthcare workers in 18 Italian Hospitals

We can’t wait so long

B. Pedersen, HEPS Oviedo, 2011

Outline

• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and

implications for the future

• Clinical information available in hospital outpatient clinics

• Prescribing for hospital inpatient• Equipment availability in the operating

theatre• Equipment available for inserting

peripheral intravenous lines

Reliability of the healthcare system

Burnett S, Franklin BD, Moorthy K, Vincent et al. BMJ Qual Saf (2012). doi:10.1136/bmjqs-2011-000442

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations

Reliability of the healthcare systems

Based on the approach of the US Institute for Healthcare Improvement (IHI):- reliability of <80 e 90%, indicates a lack of any articulated common

process, - whereas reliability of around 95% suggests the presence of a clearly

articulated process

For healthcare organisations to begin to improve the reliability: - need for articulating or documenting the process as it is expected to

function - define the required outputs. - this is a prerequisite for understanding where processes fail

Outline

• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach

and implications for the future

Understanding systems and the effect of complexity on patient care

Vincent, 2005

Patient safety practices as a system

Right antibiotic at the right moment

Correct patient identification

Clean

hands

Unified

Therapeutic

form

Prevention of Deep venous thrombosis

Nutritional

risk

Clinical audit

Incident reporting

Mortality and morbidity review

Post-partum

emorragy

Prevention of CVC infection

Pain management

Reporting never events

Management of the oral anticoagulant therapy

Preventio of dystocyia

Oncologic therapy management

Prevention of decubituus ulcers

Falls Prevention

Survellaince of the antibiotic resistance

Modified eraly warning systen

Check list

Communication of adverse event

Good practices in critical care

• Deploy Rapid Response • Deliver Reliable, Evidence-Based Care for Acute

Myocardial • Prevent Adverse Drug Events (ADEs) • Prevent Central Line • Prevent Surgical Site Infections• Prevent Ventilator-Associated Pneumonia

Berwick 122.000 Pronovost 33.000

•look-alike, sound-alike medication names;

•patient identification;

•communication during patient hand-overs;

•performance of correct procedure at correct body site;

•control of concentrated electrolyte solutions;

•assuring medication accuracy at transitions in care;

•avoiding catheter and tubing misconnections;

•single use of injection devices;

•improved hand hygiene to prevent associated infection;

Good practices in OR, surgical unit

'Nine patient safety solutions’, 2007

The rate of death was 1.5% before the checklist was introduced and declined to0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients atbaseline and in 7.0% after introduction of the checklist (P<0.001).

Surgical checklist: results

NEJM 360;5 nejm.org january 29, 2009

Certified good practices

Efficacy of the accreditation process on patient safety

Efficacia dell'accreditamento studio randomizzato che dimostra che ci sono evidenze sulla parte organizzativa

Qual Saf Health Care 2010;19: 14e21. doi:10.1136/qshc.2009.033928

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study Jeffrey et al.

The accreditation system of the Tuscany Region

Standardization of processes with definition of main phases and quality and safety standards:• Surgical pathway• Oncological/ screening pathway • Medical pathway• ER/ critical care pathway• Trauma pathway• Pediatric and obstetric pathway • Rehabilitation pathway• Mental Health and physical and psychological dependence pathway

Accreditation through autocertification and random

controls

Good Practices 2011

2011

AOUCAOUPAOUSAUOMFond. MonasterioAUSL1ASL2ASL3ASL4ASL5ASL6ASL7ASL8AUSL9ASL10ASL11ASL12

indicator voluntary

0,601,560,002,230,002,191,052,521,965,370,003,262,76

12,030,960,864,65

indicator accreditation

3,568,579,186,97

12,903,33

10,135,813,254,933,480,657,122,811,658,222,21

indicator total

4,1610,13

9,189,87

12,905,51

11,187,845,21

10,303,483,919,88

14,842,619,316,85

Number of applied patient safety practices for ecach clinical unit of the hospital

Balancing Patient safety culture

Patient safety culture in Tuscany

Best practicesAdverse events

Claims ratehttp://web.rete.toscana.it/vetrinaasl/servlet/gateway

There is a positive correlation between public disclosure and accreditation scores H Ito, H Sugawara Qual Saf Health Care 2005;

14:87–92. doi: 10.1136/qshc.2004.010629

The Disclosure

Implications for the future

• Evaluation of the adherence of the units involved to clinical/ organizational practices and national recommendations already diffused

• Standardization of processes with definition of common safety standards throughout the units involved

• Measure process indicators and outcome indicators

Sara Albolino, PHD, CRM

Riccardo Tartaglia, MD, Eur-Erg

www.regione.toscana.it/rischioclinico

rischio.clinico@regione.toscana.it

Thanks for your attention!