Download as PDF, PPTX
Uploaded byCanadian Patient Safety Institute
Learning from Leadership: how to champion the Hospital Harm Measure and Never Events
The document outlines the insights from a session on hospital harm measures and never events in healthcare, highlighting the patient safety challenges and the need for improvements. It details the definitions of never events, examples of such incidents, and underscores the significant impact of preventable harm on patient outcomes. Additionally, it addresses the collaborative efforts required from healthcare providers, policymakers, and the public to reduce these occurrences and enhance safety in the healthcare system.
More Related Content
Similar to Learning from Leadership: how to champion the Hospital Harm Measure and Never Events
More from Canadian Patient Safety Institute
).ppt.pptx](https://cdn.slidesharecdn.com/ss_thumbnails/pitriasiisrubrapillariusprpunsaved-312150203679701379-251109154320-80d3f317-thumbnail.jpg?width=640&height=640&fit=bounds)
Learning from Leadership: how to champion the Hospital Harm Measure and Never Events
- 1. cihi.ca [email protected] patientsafetyinstitute.ca [email protected] @cihi_icis@Patient_Safety @HQOntario hqontario.ca [email protected] Learning fromLeadership: How to Champion the Hospital Harm Measure and Never Events
- 2. Session Overview: Agenda ItemPresenter The patient perspective Carola Essery, Patients for Patient Safety Canada The patient safety burning platform and burning ambition Chris Power, Canadian Patient Safety Institute What is the Hospital Harm Measure and it’s alignment with Never Events David O’Toole, Canadian Institute for Health Information Tracy Johnson, Canadian Institute for Health Information Using “Never Events” and the “Hospital Harm Measure” for improvement. Gaining insights on how to support data sharing. Joshua Tepper, Health Quality Ontario Questions Closing Remarks and Meeting Evaluation
- 3. Potential Audience Question Whatcan be done to further reduce hospital harm and never events? •At healthcare facilities? •Policymaker/government role? •Patient/public role?
- 4. Carola Essery, Member Patientsfor Patient Safety Canada
- 5.
- 6. Nicholas Roberto Bravi Nov26, 1994 8lbs 6oz 6
- 7.
- 8.
- 9.
- 10. When I buya car … this is the mileage I’d like to see.. I like to know the miles and maybe whether they're highway or city miles. Any accidents? Kind’ve like the mileage on a reprocessed single use catheter, but no one will be able to tell you because they don’t track that. 10
- 11. INJURIES NICHOLAS SUSTAINEDDURING HIS PROCEDURE Stat ultrasound ~ Significant tamponade ~ No palpable pulses, no cardiac output for approx 2 minutes, CPR Failed Pericardiocentesis, Nicholas continued to deteriorate Pericardial window - transversed the liver by mistake, surgeon did not find any ventricular perforation - release of pressure stabilized Nick somewhat Continued bleeding - ER Sternotomy in the cath lab Visualization poor - to O.R (/c sternotomy) to locate source of bleeding and inspect heart further. 3 burns to top of right atrium, one 4mm perforation. Chest tubes, ICU on ventilator. kept hypothermic discharged 6 days later
- 12. 3rd Year HeavyDuty Mechanic aiming to get his Red Seal next year
- 13. Chris Power, CEO CanadianPatient Safety Institute
- 14. The patient safetyburning platform and burning ambition
- 15. The Patient SafetyBurning Platform CPSI and partners have producedreports,developed programsfor healthcare providers and boards,provided tools,engaged the public and patients, formed coalitions, and waged campaigns to make care safer. Yet a decade and more later, the overall level of harm remains disturbingly high. Among recentfindings: • In 2014-15 an estimated 138,000 hospitalizations – 1 in 18 – resulted in harm, a fifth with more than one occurrence.Anearlier study estimated that 9.2% of children experience harm while in hospital. • Over 40% of complexsurgical patients sufferharm. Patients who sufferharm are four times as likely to die in hospital than those who don’t. • An estimated 37% of seniors in nine provinces received a prescriptionfora drug (Beers list criteria) that should not be taken by this population. “It’s obvious, mistakes happen in the medical community. My expectation as a patient is that you don’t run away, that as a doctor you come back and you help me to get better instead of closing yourself in your own insecurity shell.” ~ Kapka Petrov
- 16. Preventable harm killsmore people than stroke, Diabetes, Alzheimer’s, and kidney disease…. COMBINED Every 13 minutes and 14 seconds a patient dies in Canada from preventable harm in healthcare
- 17. Two products aimedat driving healthcare improvement
- 18. What are NeverEvents?
- 19. Never events • Neverevents are patient safety incidents that result in serious patient harm or death and that are preventable using organizational checks and balances. • Never events do not imply blame; “never” is a call- to-action, not a demand or an attempt to shame mistakes.
- 20.
- 21. Methods Our approach: • modifiedDelphi approach • scan of similar/related work in other jurisdictions • consultation with subject matter experts, stakeholders, patients • national online survey of care providers, managers/planners, patients • public comment period on draft report • Final report: Never Events for Hospital Care in Canada (Sept. 2015)
- 22. Never events –our criteria Serious — A high risk that the event would cause serious harm or death (serious harm: a significant permanent change in the ability of patients to function as they did before the event) Recurring — The event is likely to happen to another patient if not addressed Identifiable — The event is easily recognized, clearly defined and not attributable to other possible causes Avoidable — Appropriate organizational barriers will prevent the event from occurring
- 23. Results – neverevents 1. Surgery on wrong body part/patient, wrong procedure 2. Wrong tissue/biological implant/blood product 3. Unintended foreign body left in patient 4. Patient death/serious harm from improperly sterilized instruments/equipment 5. Patient death/serious harm from allergies – failure to inquire, or adhere 6. Patient death/serious harm from wrong gas 7. Patient death/serious harm from 5 pharmaceutical events: • wrong route chemo, IV admin concentrated K (potassium) solution, injection of epinephrine intended for topical use, wrong concentration of hydromorphone, neuromuscular blockade without sedation/airway/ventilation
- 24. Results - neverevents 8. Failure to ID metabolic disturbance – hypoglycaemia, hyperbilirubinemia 9. Stage III/IV pressure ulcer, following admission 10. Uncontrolled movement of magnetic object in MRI 11. Patient death/serious harm from accidental burn 12. Patient elopement (highest level of observation) 13. Patient suicide (highest level of observation) 14. Infant abducted/discharged to wrong person 15. Not leaving frail patient or patient with dementia in safe environment (patient transport)
- 25. David O’Toole, CEO CanadianInstitute for Health Information
- 26. 26 Alignment of HospitalHarm and Never Events
- 27. Indicator Development atCIHI CIHI regularly develops new indicators to fill gaps in data and knowledge and provide our stakeholders with a better snapshot of the Canadian health care system. https://www.cihi.ca/en/how-is-an-indicator-developed-at-cihi
- 28. 28 The rate ofacute care hospitalizations with at least 1 occurrence of unintended harm that could have potentially been prevented by implementing known evidence informed practices What is the hospital harm measure? • Harm must have occurred after admission and required treatment or prolonged the hospital stay • Harm is categorized into 31 clinical groups, each of which is associated with evidence informed practices • Excludes Quebec and patients with select mental health diagnoses
- 30. Where does CIHIdata come from? Health information documented HIM Professionals retrieve information Diagnosis and procedure codes assigned Facilities validate data and submit to CIHI CIHI validates submissions and performs quality checks. Data is ready for analysis and reporting.
- 31. Scope of theHospital Harm Measure The following are not captured: • Near misses • An event that reached the patient but did not cause harm • Harm that was undetected during the hospital stay but surfaced after discharge • Harm to patients outside of acute inpatient care
- 33. 33 Never events capturedby hospital harm Direct Match CPSI/HQO never event category HH Clinical groups Unintended foreign object left in a patient following a procedure Retained Foreign Body
- 34. 34 Never events capturedby hospital harm CPSI/HQO never event category HH Clinical group Surgery on the wrong body part or the wrong patient, or conducting the wrong procedure Selected SeriousEvents Patient death or serious harmarising fromthe useof improperly sterilized instruments or equipment provided by the health care facility Selected SeriousEvents Any stageIII or stageIV pressureulcer acquired after admission to hospital Pressure Ulcer Patient death or serious harmdue to the administration of the wrong inhalation or insufflation gas Medication incidents Neverevents fully captured as part of a hospital harm clinical group
- 35. 35 Never events capturedby hospital harm CPSI/HQO never event category HH Clinical groups Patient death or serious harmas a resultof failure to identify and treat metabolic disturbances Hypoglycemia Patient death or serious harmas a resultof one of five pharmaceutical events 1. Medication incidents 2. Infusion, transfusion and injection complication 3. Electrolyte and fluid imbalance Wrong tissue, biological implant or blood productgiven to a patient Infusion, Transfusion and Injection Complications Neverevents partially captured by Hospital Harm data
- 37. 37 Never events capturedby hospital harm CPSI/HQO never event category HH clinical groups Patient death or serious harmdue to an accidental burn Patienttrauma (procedure- associated and patient accidentcategories) Patient death or serious harmas a resultof transportation of a frail person, or patient with dementia, whereprotocols werenot followed to ensurethe patient was left in a safeenvironment Patienttrauma (patient accidentcategory) Patient death or serious harmdue to uncontrolled movementof a ferromagnetic objectin an MRI area Patienttrauma (procedure- associated category) Neverevents captured as part of the Patient Trauma clinical group(s)
- 38. 38 Never events NOTcaptured by hospital harm measure CPSI/HQO never event category Reasonnot captured Patient under the highest level of observation leaves a secured facility or ward withoutthe knowledgeof staff The level of observation would notbe recorded on a patient’schart Patient suicide, or attempted suicide that resulted in serious harm, in instances wheresuicide-prevention protocols wereto be applied to patients under the highest level of observation The hospital harm data doesnot include self-harm Infantabducted, or discharged to the wrong person The DAD doesnot have a specific code for this scenario Patient death or serious harmdue to a failureto inquire whether a patient has a known allergy to medication, or due to administration of a medication wherea patient’s allergy had been identified The hospital harm data cannot determine whether there wasa failure to ask aboutallergies
- 39. Joshua Tepper, CEO HealthQuality Ontario
- 40. Putting Never Eventsand Hospital Harm Indicator Into Practice: 3 Reflections Dr. Joshua Tepper MD, FCFPC, MPH, MBA JANUARY 25, 2018 TWITTER: @DRJOSHUATEPPER
- 41. 41 Never Events andHospital Harm Indicator in Ontario • HQO Public Reporting • Quality Improvement Plans • Ontario Surgical Quality Improvement Network
- 42. 42 Limits of NeverEvents • Beyond the hospital. • No standard way to record these events across hospitals. • Rare • Always events?
- 43. #1 Data &Indicators Are Just the Start
- 44. #1 Data &Indicators Are Just the Start Information Knowledge Change
- 45.
- 46. 46 #3: Treat theSecond Victim: “Almost one in seven staff members (175/1,160) reported they had experienced a patient safety event within the past year that caused personal problems such as anxiety, depression, or concerns about the ability to perform one’s job.” The second Victim Phenomenon: A harsh reality of the health care profession, Susan Scott May 2011
- 47. 47 ”“Almost one inseven staff members (175/1,160) reported they had experienced a patient safety event within the past year that caused personal problems such as anxiety, depression, or concerns about the ability to perform one’s job. An alarming 68% of these clinicians reported they didn’t receive institutional support” The second Victim Phenomenon: A harsh reality of health care profession, Susan Scott May 2011
- 49.
- 50. Please respond tothe poll questions that will open when you close the call.
- 51. Learn more aboutthe Hospital Harm project and Never Events report: Links to all resources will be placed in the chat box during the webinar. Contact us at [email protected] or [email protected] or [email protected]