June 12, 2013 Proceedings of the CCHHS Quality Assurance and Patient Safety Committee

Headline News: Edward Michael, QA Committee chair, leaves that post at the end of June to assume an as-yet-unspecified, but apparently paid, role with CCHHS.

Subordinate headline: CCHHS is preparing to hire a "Patient Safety Officer," though Dr. Das (head of Quality Assurance) and her new boss Dr. Shannon (Director of Clinical Integration, including overseeing patient safety) are both already charged with this role.

These items came up as asides at a meeting consisting entirely of "Committee Education," a lecture from Das on how the hospital does and/or should respond to adverse events, ones "leading to the serious injury or death of a patient unrelated to the patient’s underlying illness." (The Joint Commission uses the term "sentinel events.") To deal with these events, hospitals search for correctable systemic flaws rather than punishing care providers.

Issues in dealing with medical error:

• If/when to disclose errors to the patient and if/when to report them to the public: the Joint Commission favors disclosure and reporting, and the State of Illinois requires reporting "but that law is never enforced."
• Three categories of error: violations (intentional), lapses (habitual because tired) and mistakes (cognitive). To handle the latter two, hospitals search for "error traps" and eliminate them or build in redundancies, so only 10% of errors reach patients. Of these, half are preventable.
• Common types of error: adverse drug reactions, procedural complications and hospital acquired conditions. In addition to "Sentinel Events," the Joint Commission publishes a list of 29 "Never Events," occurrences which will prevent reimbursement of the hospital by Medicare/Medicaid.
• CCHHS catches errors when they’re reported by providers, by phone or through the MERS computer system. It also uses surveillance, reviewing all deaths and serious injuries for signs of error. At the time of an event, the doctor calls the Medical Director who assembles a team to talk to the patient and notifies Risk Management and Quality Assurance (Das).

The System take five steps to manage an event:

1. Care for the patient. Be empathetic and apologize but don't admit liability.  Only 1/4 of errors are disclosed, but after disclosure patients perceive they’re receiving higher-quality care.
2. Conduct initial fact-finding.
3. Care for the care-giver, who’s probably upset about the error.
4. Notify the insurance company.
5. Conduct a root cause analysis.

The Joint Commission provides a detailed outline of how to conduct root cause analysis so that all potential sites of error can be identified.: the provider, communications systems, work environment, organizational culture. Unless the error is intentional, the approach avoids blaming a single provider. Experience shows that removing individuals doesn’t solve the problem, and providers won’t report errors at all if they’re punished for doing so. If there’s no problem of criminality or substance abuse, the key test for responsibility is whether another provider faced with the same situation would have done the same thing.

• The System corrects errors using strong interventions (like technology and work flow). Though it talks about avoiding weak interventions like counseling providers, counseling is actually what the System uses most often.
• Solutions are designed collaboratively, responsibility is assigned, and the initial reporters of the incident are informed of results to reinforce their willingness to report.

When Michael asked how to determine if interventions are effective, Das responded that it was too much work to find out (though the Joint Commission requires some investigation so "we try to do it:), and Shannon noted that with only 7% of adverse incidents coming to the System's attention, there's too little data to tell.

When pressed, Das said the anti-error initiatives they’ve devised will require more staffing. Shannon offered that CCHHS’s electronic systems were better than most (for data-crunching) and that this month the System will begin a baseline "culture-of-safety" survey. Michael urged them to work with Dr. Hoda (IT) to determine what enhancements to the system will catch problems automatically. Das noted there are standard interventions already in place concerning allergies and prescriptions but argued that each site requires a system tailored to its activities.

Shannon added that the System uses the "time out" technique, starting every procedure by having participants identify themselves and review their understanding of what they’re going to do, a practice which substantially reduces errors. There is one right way to do many medical procedures and using a checklist based on that right way keeps doctors from having to reinvent the wheel and risk harming the patient.

Dr. Ukoha from Stroger reported great progress in providing translation services there: the hospital now uses a phone interpretation service covering more languages than before, as well as video interpretation and interpreters on-site. Though certain "strategic areas" require a person on the spot, video and audio can plug many of the gaps. The task now is to make sure the entire medical staff is aware of the availability of this service.

--Submitted by Kelly Kleiman