Measuring and Assessing Patient Safety Neribel Claudio HCA 375 John Gomillion July 25, 2010 Measuring and Assessing Patient Safety Patient safety is such an essential part of our health care system and it helps describe quality health care. Keeping the patients safe is a challenging issue because errors and mistakes can and do happen every day. Error occurs “when a process does not proceed the way that it was intended by its designers and managers” (McLaughlin & Kaluzny 2006). According to the Institute of Medicine, medical error resulted in as many as 98,000 preventable deaths per year.
Someone has to ensure methods are taken to help reduce the possibility that errors occur, but who is responsible for taking these proper measurers? Is it society, patients themselves, physicians, nurses, nursing professors, administrators, researchers, physicians, or professional associations? Consequence, all of these entities are responsible for making sure the patient has the safest environment possible. This is a nationwide and worldwide problem that will never be completely resolved because there is always a chance that medical errors happen. Patient safety is a sensitive concept to both understand and measure.
What does it mean to be safe? a system where no errors occur, or a system in which patient harm as a consequence of error is minimized? Measurement of patient safety is difficult, due to our inability to define patient harm, and an inappropriate focus on individual error. Particular issues involves distinguishing safety from quality, the negative connotations of error, the poor relation of error with patient harm, and the emotion that surrounds preventable patient harm. Patient safety measurement has been the misuse of reported clinical incident data as a measure of patient safety performance.
According to France, Greevy, Liu, Burgess, Dittus, Weinger, & Speroff in their article Measuring and Comparing Safety Climate in Intensive Care Units, “To measure safety climate in intensive care units (ICU) owned by a large for-profit integrated health delivery systems; identify specific provider, ICU, and hospital factors that influence safety climate; and improve the reporting of safety climate data for comparison and benchmarking. We administered the Safety Attitudes Questionnaire (SAQ) to clinicians, staff, and administrators in 110 ICUs from 61 hospitals.
A total of 1502 surveys (43% response) from physicians, nurses, respiratory therapists, pharmacists, mangers, and other ancillary providers” The responses of this questionnaire help the hospital decision making to improve patient safety. Clinicians, researches and administrators implementing quality improvement programs are encouraged to take more comprehensive view of the environment, procedures and processes, practitioners associate with care delivery, and the interactions of those factors with the patient population served. (McLaughlin & Kaluzny 2006) describe that “challenges in implementing and reporting patient safety practices reflect issues around the decision to adopt, prioritization of select practices, and methodological difficulties encountered in the identification process. ” Event monitoring systems have the purpose to recognize important events based on clinical rules. Clinical triggers are flags to clinicians to point out the possibility for error.
An adverse event is a unfavorable medical change that happens after beginning the study that may or may not be in relationship to or caused by study drug treatments. A medical event is a clinically important change in physical and mental health status. Any medical event that causes clinically relevant interference with functioning, for example, headache that causes school absence or causes clinically important activity restriction. Is also any event that requires medical attention, for example a URI with visit to a doctor.
Failure Mode and Effects Analysis (FMEA) is one of the tools use to understand system failures and recognize opportunities to improve patient safety. Recently, quality improvement analysts in health care have used this tool to understand system failures and to point out opportunities to enhance patient safety. FMEA is one of the methods recommended by Food and Drug Administration, explain McLaughlin & Kaluzny (2006). It can also be consistently applied for continues quality improvement in care process from planning through performance monitoring.
FMEA structured objectives includes, a team of clinical experts involved in a high-risk process, identify a trained facilitator, meeting to discuss a care process in detail, scoring risk items on the care process and applying the indicated results. This systems permit user to organize causes in order to offer the best priority to the intervention and the highest chance of risk reduction. According to McLaughlin & Kaluzny (2006) “FEMA clearly describe and prioritize failures in such a care process and identify root causes. FEMA tools permits to organize root causes in order to give the best priority to the intervention opportunities with the highest chance of risk reduction. The Agency for Health Care and Quality (AHCQ) formed a tool to use in quality monitoring and surveillance activities by health care decision makers. McLaughlin & Kaluzny (2006) affirm that the QI are organized in the following three groups: * Prevention Quality Indicators (PQIs), ambulatory care sensitive conditions that evidence suggest may have been avoided through high quality outpatient care. Inpatient Quality Indicators (IQI), reflect quality of care inside hospitals and include mortality for medical condition and surgical procedures and volume of procedures for which there is evidence that a higher volume is associated with lower mortality. * Patient Safety Indicators (PSIs), focus on surgical complications and other events reflective of hospital quality of care. The Agency for Healthcare Research and Quality’s (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital’s available administrative data.
The Patient Safety Indicators show the quality of inpatient care and also focus on preventable complications events. The Patient Safety Indicators (PSIs) are a set of measures that screen for adverse events that patients experience as a result of exposure to the health care system. These events are usually amenable to prevention by changes at the system or provider level. PSIs are defined on two levels: the provider level and the area level. Provider level indicators provide a measure of the potentially preventable complication for patients who received their initial care and the complication of care within the same hospitalization.
Provider level indicators include only those cases where a secondary diagnosis code flags a potentially preventable. Health care organizations can reduce patient injuries by improving the environment for safety? from implementing technical changes, such as electronic medical record systems, to improving staff awareness of patient safety risks. Clinical process interventions also have strong evidence for reducing the risk of adverse events related to a patient’s exposure to hospital care. PSIs can be used to better prioritize and evaluate local and national initiatives.
Some potential actions include the following: * Review and synthesize the evidence base and best practices from scientific literature. * Work with the multiple disciplines and departments involved in care of surgical patients to redesign care based on best practices with an emphasis on coordination and collaboration. * Evaluate information technology solutions. * Implement performance measurements for improvement and accountability. * Incorporate monitoring of performance measurements in the departmental and senior leadership meetings and include in the Board quality improvement reports.
A hospital association recognizes its member hospitals’ need for information that can help them evaluate the quality of care they provide. There is significant interest in assessing, monitoring, and improving the safety of inpatient care. After learning about the AHRQ PSIs, the association decides to apply the indicators to the discharge abstract data submitted by individual hospitals. For each hospital, the association develops a report with graphic presentation of the risk adjusted data to show how the hospital performs on each indicator compared to its peer group, the State as a whole, and other comparable States.
National and regional averages from the AHRQ Healthcare Cost and Utilization Project (HCUP) database are also provided as additional external benchmarks. Three years of trend data are included to allow the hospital to examine any changing patterns in its performance. One member hospital, upon receiving the report, convenes an internal work group comprised of clinicians and quality improvement professionals to review the information and identify potential areas for improvement.
The hospital leadership is committed to performance excellence and providing a culture supportive of systems evaluation and redesign. To begin their evaluation, they apply the AHRQ software to their internal administrative data to distinguish those patients who experienced the complication or adverse event from those who did not. The PSIs provide a perspective on patient safety events using hospital administrative data, which are available and relatively inexpensive to use, and include the following 27 measures: 1.
Hospital-level Patient Safety Indicators (20 Indicators) * Complications of anesthesia (PSI 1) * Death in low mortality DRGs (PSI 2) * Decubitus ulcer (PSI 3) * Failure to rescue (PSI 4) * Foreign body left in during procedure (PSI 5) * Iatrogenic pneumothorax (PSI 6) * Selected infections due to medical care (PSI 7) * Postoperative hip fracture (PSI 8) * Postoperative hemorrhage or hematoma (PSI 9) * Postoperative physiologic and metabolic derangements (PSI 10) * Postoperative respiratory failure (PSI 11) * Postoperative pulmonary embolism or deep vein thrombosis (PSI 12) * Postoperative sepsis (PSI 13) * Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 14) * Accidental puncture and laceration (PSI 15) * Transfusion reaction (PSI 16) * Birth trauma — injury to neonate (PSI 17) * Obstetric trauma — vaginal delivery with instrument (PSI 18) * Obstetric trauma — vaginal delivery without instrument (PSI 19) * Obstetric trauma — cesarean delivery (PSI 20) 2.
Area-level Patient Safety Indicators (7 Indicators) * Foreign body left in during procedure (PSI 21) * Iatrogenic pneumothorax (PSI 22) * Selected infections due to medical care (PSI 23) * Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 24) * Accidental puncture and laceration (PSI 25) * Transfusion reaction (PSI 26) * Post-operative hemorrhage or hematoma (PSI 27) The Institute of Medicine report, To Err is Human: Building a Safer Healthy System, initiated public concern about the need to take action to reduce the occurrence of medical errors. Conquer this goal includes identifying errors in practice and initiatives to prevent them; also requires national and regional attention to monitor and report to the public about patient safety.
According to McLaughlin & Kaluzny (2006) “Retrospective monitoring tools can fill important needs in hospital quality improvement. ” Hospitals that are looking standardized measures for monitoring and benchmarking safety performance looked to the PSIs. These tools can be used to produce statistical process control chart. Measuring technical safety performance remains a significant challenge. Without reliable data on rates of patient harm in key components of care, it is impossible to know how safe we really are, and whether the investment in strategies to improve patient safety is having an impact. In the absence of such measures, it is inevitable that the focus will remain in incident reporting as a de facto performance measure.
This should be resisted for the reasons outlined above. Application of agencies such as AHRQ and FEMA will enable a more comprehensive assessment of patient safety as a basis for improvement at clinical unit, hospital, state and national levels. | | | | | | References France, D. , Greevy, R. , Liu, X. , Burgess, H. , Dittus, R. , Weinger, M. , & Speroff, T.. (2010). Measuring and Comparing Safety Climate in Intensive Care Units. Medical Care, 48(3), 279. Retrieved July 23, 2010, from Research Library. (Document ID: 1973773451). Punekar, Yogesh Suresh (2006). Development and validation of a patient medication risk reduction behavior scale and application in a managed care population. Ph. D. issertation, Purdue University, United States — Indiana. Retrieved July 23, 2010, from ABI/INFORM Global. (Publication No. AAT 3124208). Agency for Healthcare Research and Quality, Patient Safety Indicators Overview. AHRQ Quality Indicators. February 2006. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved July 24, 2010 from http://www. qualityindicators. ahrq. gov/psi_overview. htm Bielanski, G.. (2010, August). Patient safety Q&A. Briefings on Patient Safety, 11(8), 12,11. Retrieved July 23, 2010, from ProQuest Nursing & Allied Health Source. (Document ID: 2080130911). McLaughlin, C. , Kaluzny A. (2006). Continuous Quality Improvement in Health