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Maryland’s Road to Patient
Safety – Where Are We Now?
Maryland Association for
Healthcare Quality
Fall Conference
Anne Arundel Medical Center
Annapolis, MD
October 29, 2009
Vivian Miller, BA, LHRM, CPHQ,
CPHRM, FASHRM
Risk Management/Patient Safety
Specialist
Center for Performance Sciences
© MPSC, 2009
The Maryland Patient Safety Center became part of a unique
approach to patient safety that was originally developed by the
Maryland Health Care Commission (MHCC) in response to
legislation passed by the Maryland General Assembly in 2001,
which occurred almost immediately following Josie’s death.
Designated by the Maryland Legislature and the Maryland
HealthCare Commission in 2004, our vision is to make
Maryland’s healthcare the safest in the nation.
We want all Maryland hospitals tied for first place in the
provision of safe, high quality care to our entire patient
population.
© MPSC, 2009
The Maryland Patient Safety Center is a 501(c)3, non-profit
organization, and as such, is governed by a voluntary Board
of Directors comprised of Hospital Senior Executives, as well
as representatives from Academia, MHA, the QIO, OHCQ,
our patient population, and third party payors.
The Executive Director is William Minogue, MD, a retired
family practitioner and former hospital CEO
The Director of Operations and Development is Inga AdamsPizarro
© MPSC, 2009
Additionally, there is an MPSC employed Executive
Assistant, and
A programmer, along with myself, who are contracted
staff through another MHA subsidiary to provide
services on behalf of MPSC.
© MPSC, 2009
 The Maryland Patient Safety Center has since
been now re-designated as the state’s Patient Safety
Organization from January 1, 2009 to December 31,
2014
 The Maryland Patient Safety Center has also been
listed as a federal Patient Safety Organization for
three years effective December 10, 2008 through
December 9, 2011
© MPSC, 2009
 The Maryland Patient Safety Center brings together
health care providers to study the causes of unsafe
practices and put practical improvements in place to
improve the quality of care provided as well as to prevent
medical errors.
 This approach combines limited mandatory reporting of
serious adverse events to the state health department with
voluntary systems improvement activities coordinated by
a statewide patient safety center.
© MPSC, 2009
 To carry out its charge to improve quality of patient
care and promote patient safety in Maryland, the
Center focuses on the following four activities:
 Collaboratives
 Education
 Research
 Data Collection
© MPSC, 2009
 Since July 2006, the
Maryland Patient Safety
Center has been collecting
data after careful planning
of how and what should be
collected; and, what
difference it can make to
quality and safety of care
© MPSC, 2009
 Today’s discussion is about the progress we have made, and
how the data MPSC has collected over the last 4 years are
being used by Maryland healthcare providers to their
organization’s strategic patient safety initiatives.
 It is also about analyzing key aspects of structures, processes,
and outcomes of care that could have a direct impact on patient
safety, as well as evaluating an organization’s progress toward
a successful “culture of safety.”
© MPSC, 2009
Maryland Patient Safety Center Data
 MPSC’s Adverse Event Reporting System (AERS)
collects data related to
 Adverse Events
 Near Misses
 RCA and FMEA Processes
© MPSC, 2009
Top 15 Incidents Reported by Volume, 2008
25%
Percent of Total Incidents Reported
20%
15%
10%
5%
0%
Incident Type
© MPSC, 2009
Top 15 Incidents Reported by Volume, 2008
Total Number of Incidents Reported = 7,977
Incident Type
Count
% of Total Incidents Reported
Harm
No Harm
Don't Know
Ratio Harm/No Harm
Medications
1639
20.55%
73
1081
485
0.07
1:15
Falls
1068
13.39%
247
647
174
0.38
1:3
Laboratory
883
11.07%
72
382
429
0.19
1:5
Provision of Care
859
10.77%
202
277
380
0.73
1:1
Injury (needle stick, etc.)
660
8.27%
484
76
100
6.37
6:1
Medical Records
622
7.80%
12
467
143
0.03
1:39
Unexpected Departure
385
4.83%
0
105
280
0.00
NA
Security
348
4.36%
37
224
87
0.17
1:6
Other
334
4.19%
66
118
150
0.56
1:2
Communication
299
3.75%
32
152
115
0.21
1:5
Drug
250
3.13%
85
138
27
0.62
1:2
Surgical
223
2.80%
24
82
117
0.29
1:3
Equipment
215
2.70%
42
106
67
0.40
1:3
Radiological
181
2.27%
13
68
100
0.19
1:5
Patient Feedback
176
2.21%
17
128
31
0.13
1:8
© MPSC, 2009
Summary of Incidents Reported by
Volume, 2008
 Medication errors accounted for 21% of total incidents reported
 11% resulted in harm
 Falls accounted for 16%
 23% resulted in harm
 Laboratory incidents accounted for 11%
 8% resulted in harm
 Provision of Care accounted for 11% of total incidents reported
 24% resulted in harm
 Injury accounted for 8% of total incidents reported
(i.e., Abrasion/Burn/Bumps; Aspiration; Blisters Broken or Missing Teeth; Bruise; Choking; Laceration (w or w/o Stitches);
Needle Sticks; Self-inflicted Injury; Skin Tear; Struck by Object; Swelling/Edema)
© MPSC, 2009
Maryland Office of Healthcare Quality
 Finding: Per the Office of Health Care Quality, for
year 2008, Falls remain the most reported type of
Level 1 Event that resulted in serious injury, illness
and/or death. (More to come during the OHCQ
Presentation)
© MPSC, 2009
Other patient characteristics are not
reported to the OHCQ, but are
associated with high risk for falling.
 incontinence
 age-related declines
 chronic disease, acute illness
 **medications (24.17% per MPSC data)
Prevalence and Morbidity, and Causes, Chapter 21-Falls, Douglas P. Kiel, MD, MPH
© MPSC, 2009
 There is a clear relationship between falling and:
1.**Polypharmacy, (patients being on more than
4 medications for acute care, on more than 9 for
long term care)
2. Postural control, i.e., environment, changing
positions, increase or decrease in normal
activities
3. Other mediating factors, i.e., risk taking
behaviors underlying mobility level such as
disregarding fall prevention education by staff
© MPSC, 2009
This data were used to:
 Assist in the establishment of a Falls Work Group
 Develop and implement Roadmaps and Provide
Tools designed to assist healthcare facilities across
the continuum of care reduce the frequency and
severity of falls
 Data and other information was shared with the
MEDSAFE Team for presentation at the 2008
Annual MEDSAFE Conference
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
 All levels of analysis indicate that MPSC participants’
greatest opportunities for improvement are within the
following key elements
 Patient Information
 Staff Competency and Education
 Quality Process and Risk Management
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
 Greatest opportunities for improvement within the
following core characteristics:
 Essential patient information is obtained, readily
available in useful form, and considered when
prescribing, dispensing, and administering medications
 Essential drug information is readily available in
useful form and considered when ordering, dispensing,
and administering medications
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
 Practitioners receive sufficient orientation to
medication use and undergo baseline and annual
competency evaluations of knowledge and skills
related to safe medication practices
 Practitioners involved in medication use are provided
with ongoing education about medication error
prevention and the safe use of drugs that have the
greatest potential to cause harm if misused
© MPSC, 2009
Summary of 2008 Analysis Results, cont.
 A non-punitive, system-based approach to error
reduction is in place and supported by management,
senior administration and the Board of
Trustees/Directors
 Simple redundancies that support a system of
independent double checks or an automated
verification process are used for vulnerable parts of the
medication system to detect and correct serious errors
before they reach patients
© MPSC, 2009
Summary of 2008 Education Session
 Don’t Fall on Your Meds! (September 25, 2008)
 Medications’ Influence on the Risk of Falls – What the
Data Suggests
 National Perspectives on Fall Reduction Efforts
 Medications that Put Hospitalized Patients at Risk for
Falling
 Patient Falls Case Review – Diuretics and Sleep
Medications
 Falls and Medication Safety – Systems and Processes
 Discussions and Lessons Learned
© MPSC, 2009
So, what does the data show for 2009 to date?
© MPSC, 2009
Incidents Categorized by Type
January – September 2009
Total Number of Incidents - 4784
730
695
607
547
436
348
304
226
203
198 197
143 132
© MPSC, 2009
101 95 94 90 89
120
68 62
40 39 27 27 27 25 23
10 10
8
5
4
3
1
1
Incidents Reported by Volume through September 2009
Incident Type
Laboratory
Medications
Falls
Provision of Care
Injury
Medical Records
Security
Communication
Surgical
Unexpected Departure from
Facility
Radiological
Patient Identifier
Drug
Patient Feedback
Infection
© MPSC, 2009
Total number of incidents reported 4784
% of
No
Do not
Ratio Harm/No Near
Count Reports Harm Harm Know
Harm
Miss
730
15.26
9
236
485
0.04
52
695
14.53
8
522
165
0.02
143
607
12.69
204
321
82
0.64
17
547
11.43
72
202
273
0.36
28
436
9.11
346
33
57
10.48
0
348
7.27
0
280
68
0
41
304
6.35
15
203
86
0.07
7
226
4.72
8
126
92
0.06
22
198
4.14
22
77
99
0.29
6
197
143
132
101
95
94
4.12
2.99
2.76
2.11
1.99
1.96
0
9
0
14
6
10
51
46
94
57
73
13
146
88
38
30
16
71
0
0.2
0
0.25
0.08
0.77
0
6
24
0
0
0
Summary of Incidents Reported by Volume,
through September 2009
 Laboratory errors accounted for 15% of total incidents reported, up 4% from 2008)
 1% resulted in harm
 Medication errors accounted for 14% of total incidents reported (down by almost
5% from 2008)
 1% resulted in harm (down 22% from 2008)
 Falls incidents accounted for 13% of total incidents reported (up 2% from 2008)
 34% resulted in harm
 Provision of Care accounted for 11% of total incidents reported
 13% resulted in harm, (down 11% from 2008)
 Injury accounted for 9% of total incidents reported, up 1% from 2008)
(i.e., Abrasion/Burn/Bumps; Aspiration; Blisters Broken or Missing Teeth; Bruise; Choking; Laceration (w or w/o
Stitches); Needle Sticks; Self-inflicted Injury; Skin Tear; Struck by Object; Swelling/Edema)
© MPSC, 2009
Future Considerations for MPSC based
on Data
 Drill down Laboratory Errors, determine possible contributing
factors, i.e., improper collection, specimen mislabeled, patient
identification, etc.
 Drill down Provision of Care Errors, determine specific type
of error, i.e., delay in treatment, delay in diagnosis, delay in
response, etc., particularly in light of recent article published
in JAMA. 2009;301(10):1060-1062, entitled “Diagnostic
Errors—The Next Frontier for Patient Safety”, by David E.
Newman-Toker, MD, PhD and Peter J. Pronovost, MD, PhD
© MPSC, 2009
According to the article, “....although the science of
error measurement is underdeveloped, diagnostic
errors are an important source of preventable harm.”
© MPSC, 2009
Next Steps for The Maryland Patient Safety
Center (MPSC)
 Continue to develop and deploy upgrades and improvements
to the current adverse event reporting system so that data
collected accurately reflects what types of events are actually
taking place in Maryland hospitals
 Provide a routine, comparative data review and analysis for
each participating institution, including near miss data
 Provide an annual report on identified trends within each
participating institution, also including comparisons to other
regional and national data
 Provide an annual assessment of the status of patient safety
efforts in participating institutions to show how MPSC and the
Adverse Event Reporting System has contributed toward
making Maryland’s Healthcare “the Safest in the Nation”.
© MPSC, 2009
Questions?
© MPSC, 2009
For more information, contact:
[email protected]
[email protected]
[email protected]
(410) 379-6200
© MPSC, 2009