Download 2940 070820 Using local data sources for patient safety

Supporting Trusts to Use a
Broader Range of Data Sources
for Monitoring Patient Safety
A toolkit for Patient Safety
Managers
Produced by Dr Helen Hogan, Specialist Registrar
London School of Hygiene and Tropical Medicine
Learning about the scale and nature
of key risk areas: two approaches
In depth analysis of
individual PSIs
Good for identifying
underlying process
and system failures
Epidemiological
approach focusing on
analysis of groups
of PSIs
Good for identifying the
scale of the problem,
trends, clusters and
risk factors
Sources of Information on PSIs
Individual
Root cause
analysis (RCA) of
individual PSI
Population
National
Confidential
Enquiries
Local Risk
Management
Systems
Aggregated
RCAs
Patient
Administration
System
Disadvantages of relying on
single source
Local Risk Management Systems
• Under reporting at both ends (no harm and serious)
• More likely to receive reports from particular
healthcare worker groups e.g. nurses
• More likely to receive reports of certain types of
injury e.g. falls
• Relying on this source alone does not give the whole
picture
The broader approach to
surveillance and monitoring
• Bringing together information from a range of
sources provides a better picture of the scope
and scale of key patient safety risks
• Different sources identify different types of
incidents causing differing levels of harm
• International experience supports this approachrecent study by the AHRQ in the USA highlighted
the need to triangulate findings from LRMS with
other data sources to identify appropriate
interventions1
Which information sources might hold
useful patient safety information?
An example of some sources relevant to medical and surgical inpatients
Incident Reporting
Systems











Clinical Incidents
Health and Safety
Incidents
Complaints
Claims
Inquests
Medical and Healthcare
Products Regulatory
Agency Reporting System
EBME local incident
reporting system
Pathology local incident
reporting system
Infection Control Team
incident reporting system
Radiology reporting
system
Endoscopy incident
reporting system
Surveillance
Systems




Mandatory MRSA
bacteraemia
surveillance
Mandatory
Clostridium
Difficile
surveillance
Orthopaedic
Surgical Site
Surveillance
Serious Hazards
of Transfusion
Audit
Local
 ITU Outreach Nurses Audit
 Resuscitation Audit
 Pressure Ulcer Audit
 Pharmacy Audits
 Endoscopy Audit
National
 National Cardiovascular
Disease Audits
 National Sentinel Audit of
Stroke
 National Confidential
Enquiry into Perioperative
Outcomes and Deaths
 National Tonsillectomy
Audit
 National Cancer Audits
 National Joint Registry
 National Blood Transfusion
Service Audit
Other
Sources





PAS
Claims
records
Inquest
records
Morbidity
and
Mortality
Meeting
Minutes
Case
Notes
Issues to consider when choosing
which data sources to use: What type
of information is available?
• Incident Reporting Systems: equipment failures,
medication incident, complications or delays related to
diagnostic tests, admission/ discharge issues, falls
• Surveillance systems: infection control, blood
transfusions, medication incidents
• Audit: clinical assessment and initiation of treatment
issues, monitoring, problems related to treatments or
procedures
Issues to consider when choosing
which data sources to use: What type
of information is available? 2
• PAS: problems related to treatments and
procedures, infection control
• Case notes: complications or delays in
monitoring or treatment, discharge failures,
medication errors, infection control
• Complaints: communication failures, admission/
discharge failures
Types of medication incident identified by different sources
Data Source
Examples of incident detected
Clinical
Incidents
Product: side effects
Prescription: illegibility, incorrect dose, drug: drug interaction, prescription despite know
allergy, failure to prescribe current medications
Dispensing: delays in drugs reaching wards, patients discharged without TTAs
Administration: wrong drug, wrong dose, wrong patient, administration despite know allergy,
allergic reaction
Monitor: failure to monitor side effects, toxicity
Communication: failure to give instructions to patients
Case Notes
Prescription: illegibility, incorrect dose, drug: drug interaction, prescription despite know
allergy, failure to prescribe current medications
Administration: administration despite know allergy
Monitor: failure to monitor side effects, toxicity
Claims
Administration: administration despite know allergy
Monitor: failure to monitor side effects, toxicity
Inquest
Deaths following drug toxicity including renal failure and oversedation
Complaints
Prescription: failure to prescribe current medications, incorrect dose, drug:drug interaction or
side effects
Monitor: failure to monitor side effects, toxicity
Committee on
Safety of
Medicines
Drug side effects via the Yellow Card System
Audit
Quality of medical records audit: Can identify % case notes with allergy information recorded,
% illegible entries in drug charts. Pharmacy Audit: e.g. % of medical errors detected by ward
pharmacist
Inquest
Clinical Incidents
&
on
go
ing
Complaints
Co
nt
ro
l
Health & Safety
er
ro
r
Pa
t ie
nt
ac
ci d
en
t
Tr
ea
tm
en
tp
ro
ce
du
re
tio
n
le
qu
ip
m
en
t
M
ed
i ca
M
ed
i ca
In
fra
st
ru
ct
ur
e
In
fe
ct
io
n
Do
cu
m
en
ta
ti o
m
n
on
it o
ri n
g
an
d
re
v ie
w
0
Ca
re
Ac
ce
ss
,a
dm
is s
io
n,
tra
ns
fe
r
Cl
Co
in
ic a
ns
en
la
t,
ss
co
es
m
sm
m
en
un
t
i ca
t io
n,
co
Di
nf
sr
id
up
en
tiv
tia
e,
lit y
ag
gr
es
si v
e
be
ha
vi o
ur
Contribution each data source made to identifying
incidents falling into the different NPSA’s categories
100
90
80
70
60
50
40
30
20
10
Claims
PAS
Case not
Issues to consider when choosing
which data sources to use: What type
of information is available?
Proportion of incidents in different harm grades
for each data source, April 2004 to March 2005
Not possible to code
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
No harm, impact
prevented
No harm, impact not
prevented
Low
C
lin
ic
al
In
ci
de
nt
s
C
om
H
pl
ea
ai
lth
nt
s
an
d
Sa
fe
ty
C
la
im
s
In
qu
es
ts
C
as
e
no
te
s
Moderate
Severe
Death
Issues to consider when choosing
which data sources to use: How is
the information collected?
• Is it continuous or intermittent?
• How complete and detailed is the information
about incidents?
• Are there significant delays in information
reaching the source?
• How accessible is the information?
How can the Trust improve the quality
of it’s patient safety information
• Increase frequency of incident reporting by staff
• Encourage collection of risk factor/ contributory
factor information
• Ensure consistency of coding of types of
incidents on LRMS
• Collect information from departmental incident
reporting systems centrally
• Ensure Audit database is complete and up to date
• Provide time for staff to engage in retrospective
case note review
An approach to exploring incidents
related to infection control
Infection control is a key issue in patient safety but
remains under reported (0.9% of all reported incidents to
the NRLS up to March 2005). Many Trust data sources
collect information on infection control related incidents.
Which data sources identify incidents in this category?
• 211 incidents were found across a single year on
interrogation of the LRMS, a sample of case notes and
PAS in a single acute Trust
• Other potential sources include local audits,
microbiological surveillance systems and departmental
local incident reporting systems
Percentage of infection control
incidents found within each
information source
Source
% of infection control
incidents in that database
Clinical Incidents
4
Inquest
5
Case notes
(based on a sample of 220)
13
Complaints
9
PAS
39
Claims
20
Do different data sources identify different
subcategories of infection control incidents?
Contamination of
equipment/ failure to
sterilise
0.9% of all IC incidents (100% of IC incidents
found in the clinical incident database)
Cross infection/ hospital
acquired infection
55% of all IC incidents (90% of all IC
incidents found in case notes, 50% in PAS
and 38% in complaints )
Wound infection
10% of all IC incidents (11% of all IC incidents
found on PAS)
Treatment/ procedure
inappropriate
1.4% of all IC incidents (13% of all IC
incidents found in complaints)
Unsafe/ inappropriate
clinical environment
3% of all IC incidents (44% of all IC incidents
found in complaints)
Other
29% of all IC incidents (34% of all IC
incidents found in PAS)
Do different data sources detect
infection control incidents causing
differing levels of patient harm?
not possible to code
no harm impact
prevented
No harm impact
not prevented
Low
PA
S
moderate
In
qu
es
t
Cl
a im
s
Co
mp
lai
Cl
nt
ini
s
ca
l In
c id
en
ts
Ca
se
no
tes
100
90
80
70
% incident in 60
each harm 50
40
category
30
20
10
0
severe
Death
Types of infection control incident identified by different sources
Data Source
Examples of incident detected
Clinical Incidents
•MRSA positive patient admitted to clean surgical ward
•Failure to communicate information about MRSA between ward and
theatre
•Lack of isolation room for TB patient
•Contaminated instruments in theatre
•Infected intravenous line
Claims
•Post operative infection
•MRSA infection
Inquest
•Post operative infection leading to death
Complaints
•Cleanliness of hospital environment
•Staff not washing hands between patients
•Hospital acquired infection/MRSA
•Cannula left in situ on discharge
Microbiological
surveillance
•MRSA bacteraemia, C. difficile, GEC trends
•Surgical Site Surveillance: number of wound infections following knee
and hip replacement
Microbiology
departmental
reporting system
•Hospital outbreaks, microbiological environmental hazards
What can we learn about
contributory factors?
Analysis of the 9 infection control incidents
found on review of 220 case notes revealed that
the 60% of incidents occurred post procedure,
25% were related to poor catheter care and 25%
related to failure to give antibiotic prophylaxis.
When to use this approach?
• To undertake an initial investigation of an area of
concern
• To highlight the scope and scale of incidents
related to known key risk areas e.g. medication
incidents, patient misidentification incidents,
incidents related to treatments or procedures
• To identify areas that would benefit from further
assessment through methods such as audit or
case note review
What can the Trust do to support
such an approach?
• Leadership from senior management is essential to
create a culture that promotes the sharing of
information
• Incorporate this approach into clinical governance
activities
• Identify and prioritise risk areas
• Identify relevant data sources
• Provide resources and support to departments to
facilitate the collection, collation and analysis of
information
• Ensure findings are shared across the organisation
and further work is commissioned if required