Download What Families Can Do To Reduce Adverse Events

Thanks for Asking! A Family-Initiated
Adverse Event Reporting System
Mark Ansermino
Donna Tack
Jeremy Daniels
Department of Anesthesiology & Partners in Care
BC Children’s Hospital, Vancouver, British Columbia, Canada
Our Team




Mark Ansermino – Anesthesiologist, BCCH
Anesthesia Director of Research
Donna Tack – Parent of child-patient, CoChair BCCH Partners in Care committee
Jeremy Daniels – Cardiology patient (most of
life), BCCH Anesthesia Research Engineer
Katrina Verschoor – BCCH Nursing Leader,
Quality & Safety
I have made MISTAKES
I
am not bad
 I care about every patient
 I am human…..
Introduction: Patient Safety


Important term:
adverse event
Adverse event:
– an injury caused by
medical
management
– that prolonged
hospitalization, or
– produced disability
History





Lucian Leape’s work in
early 1990’s
Reviewed 30 000 NY
hospital charts
Adverse event in 3.7%
of charts!*
Big opportunity for both
hospitals and patients
But this is 2007, and
we don’t live in NY!
*N Engl J Med. 1991 Feb 7;324(6):370-6.
Closer to Home




1990’s: people began
listening
2004: 15 Canadian
researchers from BC to
NS
Looked at adverse events
in Canada
Found adverse event in
7.5% of hospital
admissions*
*CMAJ. 2004 May 25;170(11):1678-86
This is a BIG problem



1.1 million added days in hospital and $750
million in extra healthcare spending
185,000 adverse events per 2.5 million
hospital admissions in Canada per year of
which close to 70,000 are preventable
More Canadians die due adverse events in
hospitals than from breast cancer, motor
vehicle accidents or AIDS
Canadian Institute for Health Information. Ottawa, ON; 2004
Key Concepts





Increasing technology = more errors
Most errors do not result in harm (latent
error)
Many serious errors preceded by near
misses
Errors of omission (neglecting to do
something) are most common
Many errors are preventable
What can we do about it?
 Unlikely
to be achieved by
trying harder!
Culture of Safety
Measurement and
Evaluation
Legal/Regulatory
System
Changes to
Create a
Culture of
Safety
Education and
Professional
Development
Information
and Communication
Standard Initiatives

Learn from highreliability industries
–
–


Aviation
Nuclear
What makes it so safe
to fly?
Why is your car safe?
Key Technique: Reporting




Reporting system for
accidents / near-misses
Understand what’s
going on
Redesign system
You cannot manage
what you cannot
measure!
Families know!




Idea: join hands with
families
Have families help identify
adverse events
Families complete
questionnaire
Families a valuable source
of knowledge
Family Reporting of AE






Capitalize on family
knowledge / passion to help
Anonymity by default
Opportunity to participate in
solution design meetings
Provide input for real,
lasting change
? Change the culture
? Improve resilience
Our beliefs about family
Family members:
 Are key partners in the provision of
safe care
 Are knowledgeable about what we
are doing well and where
improvements can be made
 Have numerous personal stories
that can be shared for the purposes
of organizational learning and
improvement
 Want to be involved in making
healthcare safer for everybody
 Are an incredible source of
knowledge
What we encourage families and patients
to report

Anything that is an actual or potential
safety concern (mix-ups, near misses,
communication breakdown, degree of
inclusion and knowledge sharing,
discharge planning / preparedness etc.)
Ethical Considerations




Patient / family confidentiality
Organizational responsibility for follow-up on
reports
Do we have a process in place for triaging and
ensuring all reports are handled accordingly?
Joint reporting processes: Who is in the best
position to be the primary “owners” of the data
and “initiators” of change?
Canadian Patient Safety Institute (CPSI)
The Vision
“We envision a Canadian health system where
patients, providers, governments and others work
together to build and advance a safer health system;
where providers take pride in their ability to deliver
the safest and highest quality of care possible; and
where every Canadian in need of healthcare can be
confident that the care they receive
is the safest in the world.”
http://www.patientsafetyinstitute.ca/about.html
Practical Steps….

Culture is what people do when no one is
looking!
A thought to leave you with…
The true measure of quality is the
satisfaction of the receiver of the
care, not the satisfaction of the
care provider!
Shifting gears

Donna Tack now
–
Practical strategies for families
Medication Safety
A Parents Point of View
Challenges



As a parent of a chronically ill child, keeping track of
and managing administration of your child’s
medications can be daunting.
Ensuring correct dosages and times of
administration are observed when there are multiple
caregivers
Ensuring all healthcare providers are aware of all
medications your child is using prior to prescribing
additional medications.
Being aware of all common side effects and drug
interactions.
How do I do it?
When your child’s physician prescribes a drug ask:
Why this drug?
How much and when?
Common side effects?
 If cost is an issue, ask if there is a generic brand that
is EQUALLY as effective. If so, ask the doctor to
write the prescription to reflect that.



When having the prescription filled out at the
Pharmacy ask for a medication information printout.
Ensure the dosage and directions are correct on the
label. Check your child's name, the route
(oral, G-Tube, J-tube) and the amount of times per
day the medication is to be given.
Ask if there are any refills – if not, make sure you
contact the doctor in plenty of time for one. This
ensures no doses are missed.


Make the pharmacy aware of all the medications'
your child is currently taking – they may not have it
on file if you use more than one pharmacy. The
pharmacist can answer any questions you might
have about drug interactions.
Make the pharmacist your ally, explain that your child
is on multiple medications and you would appreciate
them letting you know if they see any potential
dangers, or even suggestions on ways to administer
the medications that are more effective.
Keeping Track



Get a binder and alphabetized tabs to keep drug
information printouts organized. It is a simple way to
look back at each drug if you have questions or
concerns.
Create a simple spreadsheet to keep track of
medication administration
(Medication Administration Record or M.A.R.)


Have a medication sheet that lists the dosages
(including milligrams per ml), times of day, and all
over the counter (OTC) drugs your child may be on.
This can be given to your child's health care
providers at clinic visits and emergency admissions.
Keep it up to date!!
Seems like a lot of work to me!


It is time consuming – AT FIRST – to set up some of
these systems at home, but after the templates are
set up, it is a simple matter of the occasional date
change or dosage update.
If you aren’t computer savvy, ask a friend, family
member or co-worker to help you set up the
worksheets. Only a basic knowledge of Word and
Excel are needed.
Why do it?




The most obvious – the SAFETY of your child!
Ensuring that there is never a medication you or a
caregiver have forgotten to give or not informed the
doctors about.
When you attend a doctors appointment or have an
emergency admission you are not wasting time
trying to recite and remember all the medications,
dosages and times of your child's medications. You
can simply make the best use of your and the
healthcare providers time.
It shows that you are serious about taking charge of
your child's health and expect to be seen as a valued
member of your child’s healthcare team.
How can I help?
As a health care provider working closely with
families, you can help with patient safety in
the following ways:
 When prescribing new drugs or treatments
ensure the patient/caregiver understand
completely the dosages, times, side effects
and duration of treatment for each
medication.
In the Clinic



Offer the patient/caregiver a pen and paper for note
taking
Encourage them to ask any questions they may
have regarding the medication or treatment.
Encourage them to write the answers down.
Although time is usually an issue, try not to appear
rushed – this makes most patients and their
caregivers nervous and they will generally not ask
questions they may have about
medications/treatments.
On the Ward



If there is more time for you to spend with the
patient/caregiver you could make suggestions about
managing multiple medications using the examples
that were previously shown.
When bringing medications' for administration, ask
the parent/caregiver to double check the medication
type and dose. This helps the parent feel like they
are a part of the team and is a double check against
errors.
If the parent has never administered this medication
or treatment before, allow them to give the
medication/treatment with your guidance. This helps
build confidence for when they are at home.


Be aware of resources available to families in regard
to teaching and support. For example – Tube feeding
guidelines book for families dealing with a new tube
insertion
Is there a family resource library in your hospital? A
parent advisory committee, or groups dedicated to a
certain diagnosis? Handouts or information
pamphlets available on the ward or in the hospital
that may be of interest to the families.
Why do it?




Education = empowerment.
As families are asked to take a greater role in the
health care system, we must provide them with as
much knowledge as possible.
It may seem time consuming at first, but I strongly
believe that taking the time to educate and empower
families, will result in better management in the
home and less frequent hospital admissions.
If parents are able to arrive at the hospital prepared
for clinic visits and admissions with medication lists
and pertinent information regarding their child,
valuable time will be saved.


When parents and caregivers are respected and
treated as part of the health care team, they can be a
valuable resource, providing information and insight
not possible for a health care providers point of view.
If we all work together with the common goal of
patient safety, we WILL succeed!