Utah Patient Safety Initiative

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Utah Patient Safety Initiative

• Sentinel Event Reporting Rule Revisions
• Effective Date-April 26, 2007

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Agenda

• Introductions
• National overview
• History of program
• Organizational Structure
• Initial Rules
• Lessons Learned
• IOM report
• Utah experience
• Why revisions?
• Revisions see form and rule handouts
• Future directions

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Introductions

• Patient Safety Steering Committee
• HealthInsight, IASIS, IHC, MountainStar, PCMC,
  UDOH, UHA, UHSC, UMA
• Users Groups
• Sentinel Events Marilyn Mariani, RN
  (MountainStar)
• Adverse Drug Events Linda Tyler, PharmD (U/U)
• Healthcare Acquired Infections Louise
  Eutropius/Jeanmarie Mayer (U/U)
• Iona Thraen, ACSW
• Patient Safety Director UDOH

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JCAHO Reported Events
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History of Program Organizational Structure
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Initial Patient Safety Rules

• October 2001
• Sentinel Events - Initiation of 8 general
  categories for reporting
• Deaths related to clinical service
• Wrong patient/site surgery
• Suicide
• Loss of function not related to underlying
  condition
• Patient abductions
• Discharge of infant to wrong family
• Rape
• Intentional injury
• Adverse Drug Events
• Hospital discharge data

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Lessons Learned - Deaths as a result of Adverse
Events

• Using the 2000 IOM report methodology estimated
  at the lower end, a death rate due to adverse
  events would equal 1.3/1000 admissions
• Utah had 268,652 hospital discharges in 2005
• An estimated 350 deaths (more conservative) would
  be due to adverse events
• Average SE reported is between 30-40/year a
  tenfold under-reporting

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Sentinel Events Hospitals/Ambulatory Surgical
Centers
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Sentinel Events
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Misadventures
Rate of Misadventures per 100 Inpatient
Discharges in Utah Acute Care Hospitals,
1999-2004
Data Notes Adverse event ICD-9-CM codes can be in
any of up to 9 reported diagnosis codes including
ecode(s).ICD-9-CM codes E870-E876, 998.2, 998.4,
998.7. Utah Adverse Event Classes, 2001
Version. Data Sources Utah Inpatient Hospital
Discharge Data, Office of Health Care Statistics,
Utah Department of Health 
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AHRQ - PSIs
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AHRQ-PSIs
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Adverse Events Inpatient Hospitalizations
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Adverse Drug Events Inpatient Hospitalizations
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Wrong Patient/Site SurgeriesC³

• Wrong Patient/Site Surgeries
• Types of events included wrong knee surgery,
  wrong finger digit, wrong back disk, wrong sided
  hip surgery, wrong patient for circumcision, etc.
• Users group established in 2002 as a
  collaborative between Utah Department Of Health,
  Utah Hospital Association, Utah Medical
  Association, and Health Insight. The Sentinel
  Event users group developed a survey instrument
  to inventory how patients were identified and
  marked. Results indicated wide variability
  ranging from yes/no, X marks the spot, X means no
  do not operate here, X/O, happy faces, stickers
  with scissors, physician initials, patient
  initials, etc.
• SE Users group worked to establish consensus
  standard C³ or C-Cubed Standard for Correct
  Patient, Correct Procedure, Correct Site
• C³ Standard agreed to by hospitals and ad
  published 11/6/05
• All physicians (approximately 7500) who are
  renewing their licenses through DOPL were sent a
  letter with a copy of the C³ standard with their
  renewal letter in November 2005.

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Adverse Drug Events

• Anti-Coagulants/Insulin - UHA
• Adverse Drug Effects User Group Publications
• The Advese Drug Effects (ADE) User Group was
  established to develop ways to identify events
  and ultimately reduce harm from the use of
  medications. This section is dedicated to the
  dissemination of ADE group projects and analyses
  that organizations might use for evaluating
  potential issues or events in their own systems
• Medication Reconciliation (in progress)

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Adverse Drug Events Prescription Drug Overdoses
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Adverse Drug Events Prescription Drug Overdoses
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Prescription medication overdose deaths by
implicated medicationUtah 1997-2005
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Healthcare Acquired Infections

• Users group established 2006
• Rules written and undergoing administrative rule
  process
• WEB site established for reporting
• Central Line Infections
• Employee influenza immunizations

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Why Sentinel Event Rule Revisions?

• Ten fold under-reporting as compared with IOM
  methodology
• Consistency with national standards National
  Quality Forum, JCAHO, CMS
• Need for more quantitative analysis than
  qualitative
• WEB reporting format
• Ability to establish statewide trends and conduct
  interventions
• You cannot improve what you dont measure!

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Sentinel Event Rule Revisions

• Checklist/WEB entry
• Expanded list see rule/form
• Quantitative analysis
• Regular feedback
• Revisions as needed

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Future Directions

• Request for UDOH funding (250,000)
• Integration of patient safety into existing
  public health surveillance
• Perinatal mortality review (started)
• Pediatric mortality review
• Trauma
• Others
• Geriatric trauma
• Others
• Multiple surveillance systems (voluntary
  reporting, clinical indicators, administrative
  data analysis, chart review)
• http//health.utah.gov/psi/

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