AddingtonAddington HospitalHospital

Managing Clinical Adverse EventsPresented by:

Dr J Hurst – Hospital ManagerMrs M Chinniah – Nursing & Quality Manager

19 January 2005WHO World Alliance for Patients Safety Meeting

Durban

ADDINGTON HOSPITALVISION

To achieve a quality health service through innovative and dynamic healthcare leadership.

MISSION STATEMENT

Addington Hospital is committed to providing a safe, legal, ethical, quality patient focusseddistrict and regional health service through the integration of the Batho Pele, Good Governance and Accreditation programmes, supported by information technology to achieve:

optimal, cost-effective clinical outcomes for patients within the available resources and current provincial health policy;

attraction and retention of talented staff by providing an exceptional work environment conducive to staff well being, participation, development, learning and research;

enhanced customer satisfaction ensuring the dignity and rights of patients, staff and other customers;

sound financial management;

improved co-ordination and communication with stakeholders including the promotion of partnerships with the Community and the eThekwini District Health Office.

HOSPITAL MANAGER

CORE VALUES

INTEGRITY

TRUSTWORTHY

CO-OPERATIVE GOVERNANCE

SELF AWARENESS

TEAM WORK

COMPASSIONATE CARING

ACCOUNTABILITY

DEDICATION

ENTHUSIASM

APPROACHABILITY

Some Background InformationSome Background Information

Situated on Durban’s famous Golden MileBuilt on present site in 1897 and has undergone many additions to the original complexKwaZulu Natal Public Sector Hospital

1861

First Government Hospital

Durban - Bayside

2004Hospital Beds – 512Average Occupancy Rate – 94%Admissions p.a. – 31,630Outpatients p.a. – 350,083Staff - 2500

Some Background InformationSome Background InformationContCont……....

Some Background InformationSome Background InformationContCont……....

Services offered by the Hospital:Obs/Gynae, Paediatrics, DentalGeneral Surgery, Orthopaedics, Ophthalmology, ENT, Urology,Radiotherapy and Oncology, Critical Care ServicesRehabilitative Services: Physiotherapy, Occupational Therapy, Speech TherapySupport Services: Radiology, Nuclear Medicine, Pharmacy, Anaesthetic, Laboratory, Social Work, DieteticsSpecial programmes: Prevention of Mother to Child Transmission, Voluntary Counselling and Testing, Antiretroviral rollout programme, HIV/AIDS Resource Centre, Advice Desk for Abused,Crisis Centre (Post Exposure Prophylaxis)

First Phase

Path Through Adverse EventsPath Through Adverse EventsFirst PhaseFirst Phase

Incident Reporting but on adhoc/crises intervention basis

No structured, formalised process of collation, analysis and monitoring of trends for remediation

Not integrated into Quality and Risk Management

No “Buy-in “ – Casemix/Abstracting Module

Second Phase

Path Through Adverse EventsPath Through Adverse EventsSecond PhaseSecond Phase

Re-entry into Accreditation Programme

Quality Steering Committee

In-house Risk Manager

Case Manager

Literature search for a model for Adverse Event Reporting and Monitoring

Path through Adverse Events

The Changing approach

Third Phase

Towards a Culture of Safety

Path Through Adverse EventsPath Through Adverse EventsThird PhaseThird Phase

Adapted and Adopted Adverse Event reporting and Monitoring Model

Policies and Procedures:

Quality Management and Improvement Strategy and Programme

Risk Management Strategy and Programme

Adverse Event Reporting and Monitoring

Policy Statement:Policy Statement:Quality Management and improvement Quality Management and improvement strategy and strategy and ProgrammeProgramme –– July 2003July 2003

PURPOSE: The provision of a framework for the Hospital and

the leaders to provide Patient Care in a well managed environment.

Prioritised focus for Clinical areas: Clinical audit including Adverse Events reporting and monitoring

QUALITYSAFE

Policy Statement:Policy Statement:Risk Management Strategy and Risk Management Strategy and

ProgrammeProgramme –– Jan 2004Jan 2004

1. PURPOSE: The provision of a framework to Identify, Analyse and Evaluate risks so as to reduce the frequency, severity and impact of all incidents, accidents and injuries.

2. Definition of Risk: Risk is the presence of uncertainty and it is measured as the deviation from the expected outcome of a given situation or event.

3. Definition of Risk Management: A planned Programme to prevent loss and control liability.

4. Implementation of Integrated Clinical Risk Management Model.

ADDINGTON HOSPITAL CLINICAL MX MODEL

Inpatient medical record review

Emergency Unit record review

Adverse event/clinical incident reports

Clinical Activities

Audits and Reports

Pt risk assessment tools Post mortem reportsMedia reports Consultative committees Pt complaint audits InsurersLiterature reviewsProvincial statistics

Clinical reviews

Adverse events

Detect risks

ADDINGTON HOSPITAL CLINICAL MX MODEL

Analyse and prioritise risk probabilities, consequences and risk severity

Modify the risk Accept risk(monitor)

System changesMinor changes

Evaluate

Policy and Procedure:Policy and Procedure:Relating to Adverse Events/Incident Relating to Adverse Events/Incident

reporting reporting –– Jan 2004Jan 2004

1. Purpose: As part of an integrated risk management programme that detects adverse events/incidents in the hospital; analyses their risk, and takes action to alter the rate of adverse events/incidents, procedures must be followed to report, analyse and learn from adverse events/incidents in order to improve the

and of patients2. Definition of Adverse Event: Any event or occurrence that

could have or did lead to unintended or unexpected harm, loss or damage

3. Procedure and reporting channels:

safety care

You got That???

Yeah,yeah

NOTIFICATION OF AN INCIDENT

(To be completed within 3 hours of occurrence)

Ward/department: _______________________

Date of incident: ________________________ Time of incident: ___________________________

Name of patient: __________________________________________________________________

File number: ___________________________

Diagnosis: _______________________________________________________________________

Brief description of incident:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Doctor notified (if applicable) Yes No

Persons involved:________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Notified by: ______________________________ Date: ______________________

Please forward the notification to the office of the Hospital Manager during working hours, or to the office of the Duty Matron after hours.

INCIDENT REPORTInstructions:1. To be completed within one week of notification of the incident.2. Attach the duplicate notification of the incident to this form.3. Forward to the office of the Nursing Manager.

Diagnosis:Type of Incident:Date of Incident: Time of Incident:Hospital: Ward/Department:

Report:

Comments:

Signature – Reporter: Date:Signature – Doctor if applicable:Signature – Unit Manager:Signature – Nursing Manager:Signature – Hospital Manager: Date:

Date of incident : ____________________________________________________________

Type of incident : ____________________________________________________________

Hospital : ____________________________________________________________

Intervention :____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

__ _________________________________________________________________________ Is adverse event/clinical incident risk assessment tool completed? Yes No ____________________________________________________________________________

Signature – Nursing Manager: __________________________ Date:______________

Evaluation of Intervention:_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

INCIDENT INTERVENTION

Signature – Nursing Manager: __________________________ Date: _____________

Hospital Manager: Date: --------------------

HELP……

Help

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ADDINGTON HOSPITALADDINGTON HOSPITALADVERSE EVENTS ANALYSIS FORMADVERSE EVENTS ANALYSIS FORM

Action taken ( C )

Risk severity(AxB)

Recurrence(B)

Impact(A)

Adverse event

c,d,f,h,i1644Fracture neck

of femur

Elderly patient fell out of bed

Risk severity graded against total of 2510 or < = Low grade / moderate = risk accepted>10 = SeriousRisk severity: 16Analysis: Injury in Hospital

ADDINGTON HOSPITALADDINGTON HOSPITALADVERSE EVENTS ANALYSIS FORMADVERSE EVENTS ANALYSIS FORM

ContCont…………..

10 or < 10

Accepted and will bemonitored

>10

Recommended relevant Action

1.Recircularisation & Education of P&P – cot side

2.Counselling of junior staff & supervisor for non-adherence to P&P

Risk Manager:__xx______ Date:___xx_______ Signature:_xx____

Forwarded to: 1. Quality Steering Committee √2. Health and Safety Committee √3. Unit Manager √4.

No of Adverse Events No of Adverse Events April April –– Nov 2004Nov 2004

5568TOTAL25Nov56Oct1010Sept912Aug39July79June1010May97April

ADMINCLINICALMONTH

Adverse Events Adverse Events April April –– Nov 2004Nov 2004

0

2

4

6

8

1 0

1 2

1 4

No

of E

vent

s

A p r i l M a y J u n e J u l y A u g S e p t O c t N o v

C l i n i c a lA d m i n

Adverse EventsAdverse EventsTypes of Events: April Types of Events: April –– Nov 2004 Nov 2004 -- ClinicalClinical

68TOTAL

1Missed Diagnosis

2Booked for Theatre / Cancelled

1Transfer from ward to ICU

1Delay transfer to another hospital

13Injury in Hospital

8Missing Patients

13Dispensing Error

8Death

12Treatment Delay

5Medico Legal

4Admission Delay

0

2

4

6

8

10

12

14

16

No

of E

vent

s

Adm Delay Med Legal Rx Delay Death Disp Error Missing Pts Inj in Hosp T/F to ICU Theatrecancelled

T/F to otherhospital

Md

Clinical

Adverse EventsAdverse EventsTypes of Events: April Types of Events: April –– Nov 2004Nov 2004

Adverse EventsAdverse EventsTypes of Events: April Types of Events: April –– Nov 2004Nov 2004

AdministrativeAdministrative

32TOTAL

3Invalid Consent

3Lack of Security

11Service Failure

8Misconduct

7Theft/Loss

Adverse EventsAdverse EventsTypes of Events: April Types of Events: April –– Nov 2004Nov 2004

02468

1 01 21 41 6

No

of E

vent

s

T h e f t / L o s s M i sc o n d u c t

S e r v i c eF a i l u r e

L a c k o fS e c u r i t y

I n v a l i dC o n s e n t

A d m in

1

3

9

1 8

2

7 7

1 1

3 3

1 2

1

6

2

6

0

8

01

02

01 1

02468

1 01 21 41 61 82 0

No

of In

cide

nts

1 2 3 4 5 6 8 9 1 0 1 2 1 5 1 6 2 0 2 5G r a d in g / S e v e r i t y

C l i n i c a lA d m i n

Adverse EventsAdverse EventsGrading/Severity: April Grading/Severity: April –– Nov 2004Nov 2004

Clinical Adverse EventsClinical Adverse EventsGrading/Severity: April Grading/Severity: April –– Nov 2004Nov 2004

TheatreDeath25

A&EMisdiagnosis16

Theatre x 2Death15

Med RegAdmission Delay12DepartmentAdverse EventGrading

5 Adverse Events > 10

Rates of Clinical Adverse Events Rates of Clinical Adverse Events April April –– Nov 2004Nov 2004

0 (%)27944432Outpatients

0 (%)2525736Inpatients

RatesNo patientsNo adverse events

First Phase

Second phase

Third PhaseWay Forward

The adverse clinical incident ratings The adverse clinical incident ratings and risk severities are only done for and risk severities are only done for the adverse clinical incidents the adverse clinical incidents reporting, therefore does not reflect reporting, therefore does not reflect the total adverse clinical incidents.the total adverse clinical incidents.

We need to apply incidence ratings We need to apply incidence ratings and risk severities to our other and risk severities to our other methods of clinical adverse events methods of clinical adverse events detection.detection.

ADDINGTON HOSPITAL CLINICAL MX MODEL

Inpatient medical record review

Emergency Unit record review

Adverse event/clinical incident reports

Clinical Activities

Audits and Reports

Pt risk assessment tools Post mortem reportsMedia reports Consultative committees Pt complaint audits InsurersLiterature reviewsProvincial statistics

Clinical reviews

Adverse events

Detect risks

Challenges to Challenges to optimiseoptimise a systems approach a systems approach to collection, analysis and actions to reduce to collection, analysis and actions to reduce

Adverse Clinical Incident RatesAdverse Clinical Incident RatesInpatient medical record review : Optimise our computerised Case Mix Abstracting Module which already has the ability to record Adverse EventsPost Mortem Reports: Reports, both forensic and reports to further determine the cause of death, to be channeled through the Risk Management to the Quality Steering CommitteeInsurers: Case Manager to channel all clinical audits and complaints from Insurers to Risk ManagerLiterature Reviews: More effort into Literature Reviews for benchmarkingProvincial Statistics: Not collected by Head Office currently; unable to benchmark . Challenge for Head Office

Challenges to Challenges to optimiseoptimise a systems a systems approach to collection, analysis approach to collection, analysis and actions to reduce Adverse and actions to reduce Adverse

Clinical Incident RatesClinical Incident RatesOngoing in-servicing of staff on utilisation of Clinical Adverse Events reportingOrganisation wide feedback on Adverse Events, as at this moment it is only to involved unitsCloser liaison between Risk Manager,Quality Manager, Case Manager,Infection Control Manager and Public Relation Officer to integrate data collection for analysis 6 Monthly comparative data evaluation to plot trends and patterns for remediation

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

Detecting and reducing Hospital Adverse Events: Outcomes of the Wimmera Clinical Risk Programme. MJA 2001; 174:621-625Alan M WolffJo BourkeIan A CampbellDavid W Leembruggen

Appreciation to:Addington Hospital: Informatics Team