Sara Albolino, PHD, CRMRiccardo Tartaglia, MD, Eur-Ergwww.regione.toscana.it/[email protected]
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
Thanks for your attention!
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