National Patient Safety GoalsNational Patient Safety GoalsSummits andSummits and

Patient Safety SolutionsPatient Safety Solutions

Peter B. Angood MD FRCS(C) FACS FCCMPeter B. Angood MD FRCS(C) FACS FCCMVP & Chief Patient Safety OfficerVP & Chief Patient Safety Officer

The Joint CommissionThe Joint Commission

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Things Going Bump in the Night…

• StandardsLeadershipMedical StaffEmergency Management

• Standards Improvement Initiative

• Strategic Surveillance System

• Performance Measures – NQF

• Champions for Patient Safety

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Standards

Requirements that define performance expectations with respect to structure, process, and outcomes that must be substantially in place in an organization to enhance the safety and quality for patient care

Performance Expectations – the moving targetPerformance Expectations – the moving target

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The Joint Commission’s Sentinel Event Policy

• Established in January 1996 with the following goals:To have a positive impact in improving careTo focus attention on underlying causes and risk

reductionTo increase the general knowledge about sentinel

events, their causes and preventionTo maintain public confidence in the accreditation

process

Type of Sentinel Event # %

Wrong-site surgery   625 13.0%

Suicide   596 12.4%

Op/post-op complication   568 11.8%

Medication error   446 9.3%

Delay in treatment   360 7.5%

Patient fall   281 5.8%

Assault/rape/homicide   177 3.7%

Patient death/injury in restraints   176 3.7%

Perinatal death/loss of function   143 3.0%

Unintended retention of foreign body**   141 2.9%

Transfusion error   113 2.3%

Infection-related event   100 2.1%

Medical equipment-related   82 1.7%

Anesthesia-related event   81 1.7%

Patient elopement   76 1.6%

Fire   72 1.5%

Maternal death   70 1.5%

Ventilator death/injury   50 1.0%

Abduction   28 0.6%

Utility systems-related event   24 0.5%

Infant discharge to wrong family   7 0.1%

Other less frequent types   601 12.5%

4817 total4817 total

Sentinel Events Reviewed*:

Total & Self-reported

0

100

200

300

400

500

600

700

800

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

# of non-self-reported events# of self- reportedevents

*This graph represents all RCAs reviewed and accepted in a particular calendar year.

**Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007.

*This graph represents all RCAs reviewed and accepted in a particular calendar year.

**Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007.

Sentinel Event Setting # %

General hospital 3250 67.5%

Psychiatric hospital 520 10.8%

Psych unit in general hospital 239 5.0%

Behavioral health facility 221 4.6%

Emergency department 206 4.3%

Long term care facility 145 3.0%

Ambulatory care 126 2.6%

Home care 88 1.8%

Office-based surgery 11 0.2%

Clinical laboratory 9 0.2%

Health care network 2 0.0%

Sentinel Event Outcomes # %

Patient death 3478 70%

Loss of Function 465 9%

Other 1002 20%

Total patients impacted 4945 100%

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Root Causes of Sentinel Events

0 10 20 30 40 50 60 70 80 90 100

Organization culture

Care planning

Continuum of care

Leadership

Environ. safety / security

Procedural compliance

Competency/credentialing

Availability of info

Staffing

Patient assessment

Orientation/training

Communication

(All categories; 1995-2004)

Percent of 2966 events

Average number of root causes cited

per RCA = 3.1

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Root Causes of Sentinel Events

0 10 20 30 40 50 60 70 80 90 100

Organization culture

Care planning

Continuum of care

Leadership

Environ. safety / security

Procedural compliance

Competency/credentialing

Availability of info

Staffing

Patient assessment

Orientation/training

Communication

(All categories; 2006)

Percent of 516 events

Average number of root causes cited

per RCA = 5.3

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The Sentinel Event Advisory Group

• Assess data from the Sentinel Event Database• Advise on future topics for Sentinel Event Alert• Reach consensus on candidate NPSGs• Assess practicality and cost of implementing each of

identified evidence-based NPSG recommendations• Assess comparability of alternatives to NPSG

requirements that are implemented by individual organizations

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The Joint Commission 2008National Patient Safety Goals

• 2008 Goals and associated requirements approved by Board of Commissioners June 1, 2007

• Keep the focus—Limit expansion of new requirements in 2008 and beyondHigh impactEvidence-basedCost-effective

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Moving from 2007 to 2008

• One NEW requirement under Goal #3:3E—Management of anticoagulant therapy

• One NEW goal:Goal #16—Rapid response to changes in patient

condition [Hospitals & critical access hospitals]• One-year phase-in period for 3E and 16A• Retire requirement 3B (see MM.2.20, EP #10)• Compliance with WHO Hand Hygiene Guidelines will

be acceptable for meeting requirement 7A

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2008 National Patient Safety Goals1. Patient identification

2. Communication among caregivers

3. Medication safety

7. Health care-associated infections

8. Medication reconciliation

9. Patient falls

10. Flu & pneumonia immunization

11. Surgical fires

13. Patient involvement

14. Pressure ulcers

15. Focused risk assessment (suicide; home fires)

16. Rapid response to changes in patient condition

Universal Protocol for Preventing WSS

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Goal #3: Improve safety of using medications

• Requirement #3E [AHC, HAP, CAH, LTC, OBS, OME]

Reduce likelihood of patient harm associated with use of anticoagulation therapy

NEW

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Managing Anticoagulant Therapy (1-5)

1. Defined anticoagulant management program

2. Unit dose (oral) and pre-mixed parenteral preparations

3. Dispense warfarin based on established monitoring procedures

4. Use protocols for anticoagulant therapy

5. Baseline and current INR monitoring

Continued on next slide…

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Managing Anticoagulant Therapy (6-11)

6. Notify dietary service about patients on anticoagulants

7. Use programmable infusion pumps for continuous IV heparin

8. Policy for baseline & ongoing testing for management of heparin therapy

9. Anticoagulant education to staff & patients

10. Education includes …

11. Evaluate anticoagulant safety practices

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Requirement #16A

The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when patient’s condition appears to be worsening

Goal #16: Improve recognition and response to changes in a patient’s condition

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1. Select a suitable method

2. Develop criteria for summoning help

3. Empower staff, patients, families

4. Educate requesters and responders

5. Measure utility and effectiveness

6. Measure arrest and mortality rates

Goal #16, Requirement #16A

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At 3 months—Assign responsibility

At 6 months—Work plan in place

At 9 months—Pilot testing under way

At 12 months—Fully implemented

Phase-in Milestones for 3E &16A:

  Year

NPSG Full surveys

1A Two patient identifiers

1B "Time-out" before surgery (U.P.)

2A Read back verbal orders

2B "Do not use" abbreviations

2C Reporting critical test results

2E Hand-off communication

3A Concentrated electrolytes

3B Standardize drug concentrations

3C Look-alike/sound-alike drugs

3D Label meds and solutions

4A Pre-op verification process (U.P.)

4B Surgical site marking (U.P.)

5A Free-flow protection on pumps

6A Alarm maintenance & testing

6B Alarm settings & audibility

7A CDC hand hygiene guidelines

7B HC-associated infection & RCA

8A Medication list & reconciliation

8B Transfer/discharge reconciliation

9A Fall risk assessment

9B Fall prevention program

13A Patient involvement

15A Suicide risk assessment

Hospitals

2003 2004 2005 2006 2007

1249 1528 1,573 1429 958

3.8% 4.1% 4.7% 8.1% 2.9%

8.9% 8.0% 17.3% 25.8% 21.6%

7.4% 8.2% 12.3% 15.7% 4.4%

23.5% 24.8% 38.6% 36.9% 28.3%

    9.5% 26.9% 35.4%

      6.1% 2.1%

3.0% 1.9% 1.4%    

0.6% 0.9% 1.5% 1.7% 0.4%

    2.4% 7.4% 4.5%

      8.9% 18.0%

1.5% 5.4% 4.5% 2.9% 1.0%

6.2% 4.6% 3.3% 6.6% 5.0%

0.3% 0.1% 0.1%    

1.4% 0.1%      

2.1% 1.7%      

  1.2% 3.6% 8.8% 8.9%

  0.1% 0.0% 0.1% 0.0%

    0.1% 33.9% 19.1%

    0.3% 27.5% 11.4%

    4.5%    

      6.5% 5.7%

        0.6%

        2.2%

Non-Compliance Data for 2003—07

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Sentinel Event Trends:Wrong-site Surgeries Reported by Year

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50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

S. E. Alert # 6August 1998

W.S.S. Summit IMay 2003

S. E. Alert #24December 2001

NPSGsJanuary 2003 U.P.

W.S.S. Summit IIFebruary 2007

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Wrong-Site Surgery Summit #2

• Results: Tentative consensus on

- Universal Protocol is sound but does not go far enough

- U.P. should be more prescriptive- U.P. should address “upstream” factors- Employ technology, where possible- Emphasize applicability to anesthesia procedures

and non-OR settingsDiscussion of “zero tolerance” & “campaign” strategy

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Medication Reconciliation Summit

• Sept. 25, 2007 - 85 organizations invited• NPSG 8 is important but needs clarification

• Accuracy & reliability of the list vs reconciliation• Next Provider issues• Minimal-Use scenarios• Inpatient & Outpatient• Focus on systems & processes• Focus on leadership and inter-professional teams• Patient engagement and education

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2009 National Patient Safety Goals1. Patient identification

2. Communication among caregivers

3. Medication safety

7. Health care-associated infections

8. Medication reconciliation

9. Patient falls

10. Flu & pneumonia immunization

11. Surgical fires

13. Patient involvement

14. Pressure ulcers

15. Focused risk assessment (suicide; home fires)

16. Rapid response to changes in patient condition

Universal Protocol for Preventing WSS

NO NEW NO NEW NPSGs !NPSGs !

BUT…BUT…

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There are a few There are a few DRAFTDRAFT Requirements & IEs… Requirements & IEs…

• Requirement 1A; IE 7 (Patient Identification)• Requirement 1C; IEs 1-3(Patient Identification)• Requirement 7C; IEs 1-16 (Reduce HAIs - MDRO)• Requirement 7D; IEs 1-13 (Reduce HAIs - CABSI)

Requirement 7E; IEs 1-7 (Reduce HAIs - SSI)• Requirements 8A-D + IEs (Med’n. Reconciliation)• Requirement 13A; IEs 3-4 (Patient Involvement)

• Universal Protocol; Requirements 1A-1C

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Surveying and Scoring theNational Patient Safety Goals

• All applicable Goals & Requirements, or acceptable alternative approach(es), must be implemented

• Evaluated in PPR and during all full accreditation surveys and “for-cause” surveys

• Surveyors evaluate actual performance, not just intentEmphasis is on interviews with direct caregivers

and direct observation of care delivery

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Joint Commission International Center for Patient Safety: Mission and Vision

Mission• The mission of the Joint Commission International

Center for Patient Safety is to continuously improve patient safety in all health care settings.

Vision• To become the trusted resource for improving health

care worldwide by providing pre-eminent solutions and expertise in patient safety.

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International Advisory Structure• International Steering Committee

• European Advisory Group• Middle East Advisory Group• Asia Pacific Advisory Group• Input from Latin America and Africa through WHO

Focal Points

• Communications Expert Panel• Medication Safety Expert Panel• Patient and Family Advisory Group

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Definition of Solution

• Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.

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2007 Solution topics (inaugural set)

• Look-Alike, Sound-Alike Medication Names• Patient Identification• Hand-Over Communications• Wrong Site, Wrong Person, Wrong Procedure

Surgery• Concentrated Electrolyte Solutions• Medication Reconciliation• Catheter and Tubing Misconnections• Single Use Devices• Hand Hygiene

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Topics for Next Round of Solution Development

• Follow-up on Critical Test Results • Patient Falls • Healthcare Associated Infections – Central Lines• Pressure Ulcers• Response to the Deteriorating Patient• Patient and Family Involvement• Apology and Disclosure• Look-alike Sound-alike Medication Packaging

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Action on Patient Safety:High 5s Project Goals

• To achieve significant, sustained, and measurable reduction in the occurrence of 5 patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning network that fosters the sharing of knowledge and experience in implementing innovative, standardized, safety operating protocols.

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High 5s Solution Topics

• Hand-over communications• Wrong Site, Wrong Procedure, Wrong Person

Surgery• Medication Reconciliation• Concentrated Electrolyte Solutions• Hand Hygiene

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For more information:

Joint Commission International Center for Patient Safetywww.jcipatientsafety.org

The Joint Commission Resources Web Sitewww.jcrinc.com

The Joint Commission Web Sitewww.jointcommission.org