Transcript The Canadian Adverse Events Study: the incidence of

The Canadian Adverse Events Study:
the incidence of adverse events in hospitalized
patients in Canada
Peter Norton
Professor and Head
Department of Family Medicine
University of Calgary
Canada
ENSP-FIOCRUZ May 31, 2006
Brazil
Canada
Area (sq km)
8,511,965
9,984,670
Population
188,078,227
33,098,932
Density per sq km
20
3.5
Life expectancy
72.0
80.2
% of GNP spent on health
(2003)
7.6%
9.9%
MDs per 1000
1.15
2.14
The Canadian Adverse Events Study:
the incidence of adverse events in hospitalized
patients in Canada
CMAJ May 25, 2004
• Authors
G. Ross Baker, Peter G. Norton, Virginia Flintoft,
Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells,
William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne,
Luz Palacios-Derflingher, Robert Reid, Sam Sheps, Robyn Tamblyn
• From
The Universities of Toronto, Alberta, British Columbia, Calgary,
L’Université de Montreal, McGill University and Dalhousie University
Reviewers
Nova Scotia: Brenda Brownell, Dr. Tom Casey, Dr. John Fraser, Kelly
Goudey, Dr. Ron Gregor, Celeste Latter, and Dr. Allan Shlossberg
Québec : Dr. Edouard Bastien; Dr. Richard Clermont, Evelyne Jean,
Cécile Lavoie, Dr. André Rioux. Julie Robindaine, and Daphney StGermain
Ontario: Dr. Ed Etchells, Virginia Flintoft, Wilhelmine Jones Dr. Peter
Kopplin, Dr. David MacPherson, and Elaine Thiel
Alberta: Fatima Chatur, Dr. Leslie Cunning, Dr. Peter Hamilton, Dr.
Narmin Kassam and Carolyn Nilsson
British Columbia: Karen Cardiff, Dr. Robert Crossland, Dr. Iain Mackie,
Cheryl Marr, Dr. Jacob Meyerhoff, Eva Somogyi and Dr. Robert
Wakefield
The CAES
• First national study of the incidence of adverse
events in Canadian healthcare
• Based on methods used in the Harvard Medical
Practice Study, developed further in the Australia
and UK studies
• Uses reviews of hospital records to identify adverse
events and assess whether these events might be
prevented
• Study initiated in 2002 and data collection was
completed Fall 2003
• Study funded by CIHI and CIHR
• Paper published in the CMAJ May 25, 2004
Study Goals
1. To identify the incidence of adverse events in a
representative sample of Canadian hospitals
2. To compare the incidence between medical
and surgical patients and between different
types of hospitals
3. To compare the incidence to results from
similar studies in England, Australia, New
Zealand and elsewhere
4. To compare results from chart based review
obtained from administrative data and hospital
incident reporting systems (not reported in
initial article)
Adverse Event
• Bad outcomes from care
• An adverse event is “an unintended injury or
complication which results in disability,
death or prolonged hospital stay and is
caused by health care management”
(Wilson et al.)
• Some AEs are not preventable
• Some errors do not cause AEs
• Adverse event = focus on outcome and
patient experience
• Error = focus on process and often on the
practitioner
Chart indicates penicillin allergy
but pen ordered and given and
patient has severe allergic reaction
Adverse
Events
Errors
No history of penicillin allergy
and pen ordered and given and
patient has severe allergic reaction
Penicillin given at a dose of 500mg
when 250 mg ordered and patient
progresses as expected
What was known when we
started
Previous studies
Country
N
Publication
year
Incidence of
AE
Incidence of
Error
USA (HMPS)
30,121
1990
3.7%
-
Australia
14,000
1995
16.6%
51%
USA (Utah &
Colorado)
15,000
2000
2.9%
-
England
1014
2001
11.7%
50%
New Zealand
1326
2001
10.7%
71.8%
Denmark
1097
2001
9.0%
40.4%
Methods
• Five Province - BC, AB, ON, QC and NS
• 1 teaching, 1 large and two small hospitals
from each
• Randomly selected charts for adult
patients from fiscal 2000
– 230 for large and teaching
– 142 for small
• Obstetrics or psychiatry were excluded
Methods
• Five Province - BC, AB, ON, QC and NS
• 1 teaching, 1 large and two small hospitals
from each
• Randomly selected charts for adult
patients from fiscal 2000
– 230 for large and teaching
– 142 for small
• Obstetrics or psychiatry were excluded
Methods
• Five Province - BC, AB, ON, QC and NS
• 1 teaching, 1 large and two small hospitals
from each
• Randomly selected charts for adult
patients from fiscal 2000
– 230 for large and teaching
– 142 for small
• Obstetrics or psychiatry were excluded
• This sample has the power to detect a real
difference in AE rates of at least 3%
between these types of hospitals,
assuming an incidence of 9% (range
6.9%–11.1%, α = 0.05, β = 0.1)
Methods
• Five Province - BC, AB, ON, QC and NS
• 1 teaching, 1 large and two small hospitals
from each
• Randomly selected charts for adult
patients from fiscal 2000
– 230 for large and teaching
– 142 for small
• Obstetrics or psychiatry were excluded
First Stage Chart Review
• Nurses first reviewed and selected those with one or
more of 18 “triggers” for MD reviews
• Triggers included (partial list):
–
–
–
–
–
–
–
–
Unplanned admission before index admission
Unplanned readmission after discharge from index admission
Hospital incurred patient injury
Adverse drug reaction
Unplanned transfer from general care to intensive care
Unplanned return to OR
Development of neurological deficit not present on admission
Unexpected death
• 40.8% of charts were positive for one or more of the
triggers
Physician Review
• First determined if an adverse event had
occurred
– Was there an unintended injury or complication?
– If so, did it result in disability, death or prolonged hospital stay?
– If so, was it caused by health care management?
• When an adverse event was present
–
–
–
–
–
Nature of the adverse event
How care might have contributed to AE
Effects of AE on patient and use of hospital resources
Factors contributing to the nature of AE
Preventability
Results
• In the 3745 charts reviewed 858 (22.9%) were found to have
1133 injuries or complications
• In 401 charts one or more injuries resulted in death, disability
at the time of discharge or prolonged hospitalization
• 255 hospitalizations had one or more of these that rated 4 or
higher on the 6-point causation scale – i.e. an AE
• The total number of AEs was 289 - twenty-seven (10.6%) of
the hospitalizations with AEs had more than one AE
• After weighting for the sample frame, the overall AE rate was
7.5% [CI 5.7 -9.3] – this means 1 in 13 had an AE
• After correcting for case mix teaching hospital had
significantly more AEs than did either large or small hospitals
• Preventable AE rates were the same across the 3 hospital
types (~ 3%)
Disabilities and LOS
• 65% of AEs resulted in either no disability or minimal and
moderate impairment with recovery within 6 months
• 5% of AEs (N=15) resulted in permanent disability
• 40 patients who had a total of 46 AEs died
• An estimated total 1.6% of people hospitalized in
Canadian hospitals in 2000 died and had an AE [CI =0.9
to 2.2%]
• Physician reviewers estimated that the 255 patients with
AEs required an additional 1521 days in hospital directly
related to their adverse event
Extrapolation
• Our results suggest that in fiscal year 2000
between 141,250 and 232,250 acute care
hospitalizations could have been
associated with an AE out of 2,500,000
similar hospitalizations in Canada
• The number of patients who had
preventable adverse events and later died
ranged from 9,250 to 23,750
Comparisons
• Our rates are lower than those found in several
other large studies of AEs outside of the US
• The number of AEs associated with death or
permanent disability is similar in this study to the
recent UK, New Zealand and Australian studies
• The 2001 UK study of two teaching hospitals
identified a rate of AEs(10.8%)that is nearly
identical to the rate identified in the five
Canadian teaching hospitals in this study
(10.9%)
Types of Adverse Events
Most Responsible Service
Type of AE
Diagnostic
Medicine
Surgery
Other
Total
26
11
1
38
10.6%
Surgical
6
115
2
123
34.2%
Fractures
2
5
1
8
2.2%
Anaesthesia
1
6
0
7
1.9%
Obstetric
0
1
0
1
0.3%
Medical Procedure
16
9
1
26
7.2%
Drug/Fluid
69
15
1
85
23.6%
Other Clinical
Management
30
11
2
43
11.9%
Adverse Events not
covered elsewhere
9
8
1
18
5.0%
System Event
3
4
4
11
3.1%
162
185
13
360
45.0%
51.4%
3.6%
Total
Types of Adverse Events
• By examining the individual stories of the
AEs we determined that that the most
common are:
– failures in diagnosis
– prescription of contraindicated drugs
– incorrect management of organ failure
Where do the AEs occur?
• Just over 40% of the AEs are classified as
having occurred on the ward
• 27% occur in the OR
• 17% in out patient settings
Is the number right?
• The CAES as designed gave a systematic underestimate of the
rates
• The reasons:
– The first level review selected 40% of charts for second review
which determined if AEs had occurred. This was done using
triggers that select charts with higher probability for AEs
however some of the charts not selected will have AEs
– The reviewers only had access to the chart. Many AEs occur
and are not recorded in the charts
– Some of the charts randomly selected for review were not
available to the reviewers (others were substituted). The
reasons charts are not available include being in the hands of
lawyers and coroners, being in the hands on management who
are dealing with complaints or incidents and that the patient has
been readmitted. All of these increase the likelihood that that
chart contained an AE.
• Both the literature and experts believe that the methods used in the
CAES find between ⅓ and ¼ of the actual AEs
Dissemination and Impact
• Paper was downloaded over 25,000 times
in the first four days
• Over 40 national and regional media
contacts in the first 4 weeks
• Multiple presentations over the next year
• Acceleration of patient safety initiatives in
Canada
What happened in the media?
•
“Medical errors kill 24,000 per year; rates
double those of US”
– National Post May 21 2004
1. Study estimate is 16,500 not 24,000
2. Rates not directly comparable to US studies
Canada
• Quality
• Exclude low risk
• Events detected 12
months after index
• Events occurring 12
mos prior to index
• 2000
vs
US
• Medicolegal
• No
• No
• No: 6 months if under
65
• 1984 & 1992
The Globe and Mail
•
“Study shows that medical mistakes
affect about 7.5% of patients”
– Picture of 4 yr old who died
No:
2.8% preventable adverse events
Why did we do a Canadian study?
• It appears that a critical element for accelerating
safety work is that a country has its own data
• However the number is an underestimate and so
the method cannot be used as an outcome
measure for safety
• We believe that modeling can be carried out on
the data to delineate:
– Possible areas for improvement
– High hazard situations
– Management opportunities
Additional results from the
CAES
Possible areas for improvement
What about age?
Percent of types of AEs by age category
60.00%
50.00%
40.00%
Preventable
Permanent disability
30.00%
20.00%
10.00%
0.00%
30-49
50-69
Age
Note: 1. There were only 215 files reviewed for patients with age
less than 30 and only 8 had AEs. Due to these small numbers
we have chosen not display these data.
2. The differences in the permanent disability by age is
significant (chi-square = 12.1, 2 df, p = 0.002)
70+
Relationship of LOS and AE occurrence
• We reported that those with AEs had longer LOS
(small = 7.7, large = 3.6 and teaching = 6.2
days)
• We asked if LOS increase was associated with
increased risk of AE
• When should we review patient as LOS
increases?
LOS (days)
0-2
AE
No
Count
%
Yes
Count
%
Total
Count
3
4-5
6-7
8-11
12 or more
509
489
771
538
579
600
96.4%
97.0%
96.3%
94.1%
92.1%
84.9%
19
15
30
34
50
107
3.6%
3.0%
3.7%
5.9%
7.9%
15.1%
528
504
801
572
629
707
LOS (days)
0-2
AE
No
Count
%
Yes
Count
%
Total
Count
3
4-5
6-7
8-11
12 or more
509
489
771
538
579
600
96.4%
97.0%
96.3%
94.1%
92.1%
84.9%
19
15
30
34
50
107
3.6%
3.0%
3.7%
5.9%
7.9%
15.1%
528
504
801
572
629
707
Pearson Chi-Square = 111.2, 5 df, p<0.0001
Linear-by-Linear Association = 83,3, 1 df, p<0.001
LOS -days
So what is next?
The research
• Additional studies are underway now
– Family medicine (community based care)
– Home care
– Mental health
– Long term care
– How and why institutions learn from AEs
Applied research
Quality improvement
Improving the system
Safer Healthcare Now!
• A grassroots campaign
• Implementation of six targeted and proven
interventions in hospital based patient care
• Credible evidence that these six
interventions can make a real difference in
reducing avoidable adverse events and
lead to reduced mortality and morbidity
• All are ‘low tech’
6 Key Interventions
• Deployment of Rapid Response Teams
• Delivery of reliable, evidenced based care
for acute myocardial infarctions
• Prevention of ADEs
• Prevention of central line infections
• Prevention of surgical site infections
• Prevention of ventilator- associated
pneunomia
Eg. Surgical Site Infections
• Four specific activities
– Don’t shave the skin but clip the hair
– Make sure prophylactic antibiotics are given
(and stopped) on time
– Carefully monitor and control the blood sugar
during the operation
– Carefully monitor and control the body
temperature during surgery
A Canadian Campaign
• Informed by the American effort
• Launched on April 12, 2005
• Goal was to enroll 100 or more frontline teams
to work on improvement and safety December
2006
• Four regional nodes
• National faculties for each intervention
• National coordinating group
• Support for measurement
– National and local
Key Campaign Principles
•
“Some is not a number; soon is not a
time.”
•
Welcome anyone at any level.
•
We do this together (i.e. we are forming
‘communities of practice’)
Campaign Elements
• Platform – The scientific basis for our work
• Measurement – How we measure our
progress (both process and outcomes)
• Field Operations – How we spread the
Campaign across the country and
implement improvements successfully
• Communications - How we publicize the
Campaign’s progress and successes
Who is involved?
•
•
•
•
•
Administration: Approves and
provides organizational support for
the SHN campaign
Teams: Frontline healthcare
providers who intend to implement
the initiatives
Patients and Families: Provide
feedback and information to teams
Communication Teams: Raise
awareness of the campaign both
internally and externally
Safer Healthcare Now!: Provide
ongoing support to teams within
their jurisdiction
Safer Healthcare Now!
Teams
Patients and
Families
Communicators
Administration
Progress
• Current enrollment of 409 teams enrolled from 152
health care organizations across Canada
• Nodal activities include the following:
–
–
–
–
Raising awareness of the campaign
Promoting enrollment
Facilitating educational opportunities
Coordinating clinical quality improvement and assistance
measurement
– Sharing information among the nodes
– Monitoring progress and facilitating resolution of challenges
within the geographic node
• National activities
– Coordination
– Measurement
– Sustainability
Some sucesses
• Sevearal organizations with no VAP for six
months
• Several pediatic hospitals with no CL
infections for six months
• Early indications of reduced mortality in
the ICUs of several hospitals
Why Participate in SHN?
“To not participate is not an option, It is not about spending additional
health care dollars, rather it is about our obligation to provide a safe
clinical experience for the patients who walk through our doors and
put their trust in us.” David Rowe, Senior Vice-President, Credit
Valley Hospital, Ontario.
“The SHN has provided us with leadership and coordination of the
interventions. As well, there has been excellent information sharing
and collaboration with those participating in the interventions within
and across the nodes.” Kim Cook, Vice-President of Patient
Services & Chief Nursing Officer, Headwaters Health Care Centre,
Alberta.
Safety is not a program, it is a
way of life