Transcript Reducing harm from falls

Health Quality and
Safety Commission
HQSC role and purpose
To lead and coordinate work across the health and
disability sector for the purposes of:
• monitoring and improving the quality and safety of
health and disability services
• helping providers across the health and disability
sector to improve the quality and safety of health and
disability services
How the Commission adds value
Shining the
light on
variation, and
key areas for
improvement
16/07/2015
Being an
intelligent
commentator
and advocate
for change
Lending a
hand by
making expert
advice,
guidance and
tools available
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HQSC strategic priorities
• Monitor and report on quality & safety
• Build sector capability for quality & safety improvement
• Support clinicians to be leaders of quality and safety improvement and
follow best practice
• Build consumer engagement and partnership
• Support reporting & management of health care incidents
• Manage mortality review functions
• Influence the health quality and safety agenda and be a catalyst for
change
• Ensure success in our programme areas:
– Medication safety - reducing harm from falls
– Perioperative harm- Infection, prevention & control
A picture of mortality review
Reportable Events focus so far
• Annual Serious Adverse Event Report, and Serious Mental Health
Event Report
• Establishing relationships across health and disability sector
• Improving the scope and quality of reporting. Private hospitals
• Implemented RL6 system within HQSC
• Appointed David Sage as Clinical Lead and established an Expert
Advisory Group
• Developed a strategic work-plan
Trigger Tools 2014/15
• ADE / GTT embedded in all DHBs
• Improvement work integral part of all DHBs ADE / GTT work
• Support for on-going sharing of data through:
– site visits
– active network
– Strong regional networks with clinical leads
• Explore potential for linking GTT & SAE programmes
• Work with CMH Safety in Practice Programme to pilot a Primary
Care TT
• Links established with international community through IHI Forums
Medication Safety priorities
• Safer prescribing, dispensing, administration and
monitoring of medicines
– National Medication Chart and electronic prescribing and
administration
• Improving the transfer of medicine information at
transition points of care
– Paper based and electronic Medicines Reconciliation
– Partnership with the National Health IT Board for eMedicines
Programme
Medication Safety priorities
• Reducing harm from high-risk medicines and situations
– Alerts, look-alike sound-alike medicines eg tall man lettering,
labelling, health literacy
– Scoping of improvement programme for opioids
• Providing expert advice and strategic thinking on medication
safety
– Med safety watch, networks, contribution to strategy,
evaluation of Hospital eMedicines implementation
Reducing harm from falls
730 serious adverse events, 365 patient falls, 170 falls
associated with a hip fracture (2010-2012 DHB SAE reports)
The direct costs of patient falls in hospitals for 2010-11 was
between $3-5 million
Interventions highlighted as part of the campaign:
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Risk assessment
Individualised care planning
Safe environments
Vitamin D
Strength and balance
Healthcare Associated Infections
• Up to 10 percent of patients admitted to hospitals in
developed countries acquire one or more infections during
their stay.
• Approximately 30 percent of patients in intensive care units
(ICUs) are affected by at least one HAI (WHO, 2011).
• HAIs can cause severe complications, and even deaths,
particularly among people with pre-existing conditions.
• In the late 1990s, the costs of dealing with these infections
in our public hospitals were estimated at $137 million per
year
HAI focus so far
Hand Hygiene programme:
Compliance rates have increased from 62.1% (Oct 2012) to 71.2% (June
2013)
Central Line Associated Bacteremia (CLAB) Programme:
CLAB infection rates have decreased from 3.5 per 1,000 line days to 0.44
per 1,000 line days.
Surgical Site Improvement Programme
Established and collecting data from 20 DHBs
Current focus on hips and knee surgery expanding to cardiothoracic
surgery soon
Surgical site infections
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Occur in approximately 2–5 % of patients undergoing inpatient surgery
A patient with an SSI costs approximately twice the amount of a patient without
an infection.
SSIs following joint replacements are strongly associated with increased morbidity
& mortality, prolonged hospital stay & long-term antibiotic treatment
SSIs following open heart surgery extend the length of hospital stay by an average
of 32 days at an average cost of NZ$45,000 per patient
Interventions highlighted as part of the programme to date:
• streamlining the surveillance process
• appropriate prophylactic antibiotics, right time, drug, dose
• skin preparation
• clipping not shaving
Perioperative Harm
What is it and how can we
reduce it?
Reducing perioperative harm
• An undesirable outcome (harm) associated with
any aspect of an operation (intervention)
• Preoperative
• Intra-operative
• Post-operative
• Slips, lapses (omissions), mistakes and violations
leading to harm
Perioperative harm includes
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DVT/PE
Wound infection
Medication error
Wrong side/site surgery
Retained objects
Falls
Any other complication
Reducing perioperative harm
Facts and figures
• Over 300,000 publicly funded operations are performed in New
Zealand each year
• ACC accepts between 20 and 50 claims per year for
personal injury due to surgical error.
• Perioperative harm events made up 36 percent of
non-mental health serious and sentinel events reported
to the Commission in 2012/13, including seven wrong
patient, site or procedure cases.
Mr Ian Civil,
Clinical Lead
Perioperative Harm Reportable Events
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35
Injury through use of restraint*
30
Burn*
Epidural related incident*
25
Medication error*
Contamination*
20
Wrong implant
Wrong site
15
Wrong procedure
Equipment failure*
Wrong patient
10
Retained item/swab
5
0
2009/10
2010/11
2011/12
2012/13
2013/14
A few 2012/13 Serious Adverse Events
• Bilateral brachial plexus injury as a result of
positioning during surgery
• Burn from chlorhexidine igniting
• Air in bypass system resulting in cerebellar
infarct
• Wrong patient had cardiac procedure
• Infected pacemaker sites (x3) due to
inadequate skin-prep
Foreign body - results
Reducing perioperative harm
Effective interventions
• Perioperative harm can be reduced by:
o effective team work and communication
strategies
o effective use of all three parts of the World Health
Organization (WHO) Surgical Safety Checklist
o appropriate treatments against the formation of
blood clots.
Lets talk about the Checklist
• The WHO surgical safety checklist has a core set of
safety checks that should be performed every time:
sign in; time out; and sign out for every operation
• Effective use of the checklist by DHBs in New Zealand
is likely to lead to an estimated 21–36 percent
reduction in avoidable complications from surgery
• This could save the New Zealand health system $5.7
million per annum.
Attitudes to using the checklist in NZ
• Lack of understanding of the overall intent & applicability
• Not seen as a tool to support patient safety, teamwork and
communication
• Lack of clinical buy-in/engagement
• Lack of local evidence of benefits
• The sign-out phase is not implemented well
• Discussions relating to anticipated critical events happen too late in
the process
• Checklist is complex with too many checks and perception of
duplication with other checks
We Are Not as Good as We Think
Makary et al., J Am Coll Surg 2006; 202: 746-52
We are very good at what we
do….
We can be even BETTER
Reducing perioperative harm
Use team briefings at the beginning of
the list
Improve teamwork
and
communication
Use the WHO surgical safety checklist
for each patient
Use team debriefing at the end of the
list
Reduce
Perioperative
Harm
Use evidence
based
interventions
Appropriate use of VTE prophylaxis
Additional interventions as programme
develops
HOW YOU ACT DURING THE
CHECKLIST & BRIEFING MATTERS
• Surgeons - the Team is looking to you for leadership.
• You are setting the tone for the rest of the operation.
• Others will follow your patterns of communication.
• This is an opportunity to make your plan clear, answer
questions, demonstrate openness and professionalism.
What Can You Do?
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Activate people by using their names.
Set the Tone – Make everyone feel “safe”.
Tell the team what you are going to do.
Encourage team members to speak up.
Stop to Debrief at the end of the case.
Patient Safety Campaign
Perioperative Harm is the focus of the Open Patient safety
campaign April – September 2014
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April – the Case for Change
May – Surgical Safety Checklist
June – Briefing and Debriefing
July – Risk Assessment for VTE
August – VTE – appropriate prophylaxis
September – celebrating successes
How can you get involved?
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Ask us questions
Participate in the campaign
Let us know what you would like covered in the campaign
Volunteer to be a champion for the programme
Talk to your colleagues about what we are trying to achieve
Thank you