Center for Patient Safety Research and Practice

David Bates, MD, MScCenter Director

Overview BackgroundBackground Accomplishments to dateAccomplishments to date

Before the CenterBefore the Center Of the Center itselfOf the Center itself Other relatedOther related

Future visionFuture vision

Safety and Systems

““Every system is perfectly Every system is perfectly designed to achieve exactly the designed to achieve exactly the results it gets.”results it gets.” Donald Berwick

“Safety is a systems property.”

Chasm Report

National Developments

CMS announced plan 4/14 to stop paying CMS announced plan 4/14 to stop paying for Serious Reportable Adverse Events for Serious Reportable Adverse Events (“never” events)—n=28(“never” events)—n=28

FDA has announced plans to develop FDA has announced plans to develop “Sentinel Network”“Sentinel Network”

Agency for Healthcare Research and Agency for Healthcare Research and Quality devoting few resources to safety Quality devoting few resources to safety research (main recent focus HIT)research (main recent focus HIT)

BWH As A Leader:Inpatient Prevention—Computerized Physician Order Entry

55% reduction in serious medication 55% reduction in serious medication error rate with CPOEerror rate with CPOE

Bates, JAMA, 1998Bates, JAMA, 1998

83% reduction in overall medication 83% reduction in overall medication error rateerror rate

Bates, JAMIA, Bates, JAMIA, 20002000

NEPHROS studyEffect of real-time decision support for Effect of real-time decision support for

patients with renal insufficiencypatients with renal insufficiency Of 17,828 patients, 42% had some degree Of 17,828 patients, 42% had some degree

of renal insufficiencyof renal insufficiency Interv ControlInterv Control

DoseDose 67%67% 54%54%FrequencyFrequency 59%59% 35%35%

Length of stay 0.5 days shorter Length of stay 0.5 days shorter

Chertow et al, JAMA 2001

Medication SystemsThen and Now

THEN

NOW

Slide Courtesy of Anne Bane, RN, MSN. Brigham and Women’s Hospital

BCMA

Medication Medication LocationLocation

Real Time Alerts to Nurse

Slide Courtesy of Anne Bane, RN, MSN, Brigham and Women’s Hospital

Dispensing Errors and Potential ADEs: Before and After Barcode Technology Implementation

0.19%

0.61%

0.88%

0.07%

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

Dispensing Error Rate Potential ADE Rate

Before Period (115164doses observed)After Period (253984doses observed)

Projections for errors Projections for errors

prevented per yearprevented per year at at study hospitalstudy hospital::

>13,500 medication >13,500 medication dispensing errorsdispensing errors

>6,000 potential >6,000 potential ADEsADEs

31% reduction*

63% reduction*

* p<0.0001 (Chi-squared test) Poon, Ann Intern Med, 2006

Formal Cost Benefit Analysis Results

5-year cumulative costs = $2.3M5-year cumulative costs = $2.3M $1.4M one-time investment (pre go-live, $1.4M one-time investment (pre go-live,

first 2 years)first 2 years) $343K/yr recurring (post go-live, last 3 $343K/yr recurring (post go-live, last 3

years)years) 5-year cumulative benefits = $5.5M5-year cumulative benefits = $5.5M 5-year cumulative net benefit = $3.3M5-year cumulative net benefit = $3.3M Break-even within 1Break-even within 1stst year after go-live year after go-live

Maviglia, Arch Int Med 2007

Improving the Response to Critical Labs Baseline revealed that a third not treated for 5 Baseline revealed that a third not treated for 5

hourshours Mean time to treatment11% shorter Mean time to treatment11% shorter Mean time to resolution 29% shorterMean time to resolution 29% shorter Mortality was 7% in intervention group, 13% Mortality was 7% in intervention group, 13%

control group (p=0.19)control group (p=0.19) 95% physicians pleased to be paged95% physicians pleased to be paged

Kuperman, JAMIA 2000

Coverage-Related Events Before data showed patients being cross-Before data showed patients being cross-

covered at 5-fold excess risk of adverse covered at 5-fold excess risk of adverse eventevent

After computerized signout introduction, no After computerized signout introduction, no excess riskexcess risk Included medicationsIncluded medications

Simple from informatics perspective but Simple from informatics perspective but major benefitmajor benefit

Petersen, Jt Comm Jl

Take-Away Messages of Smart Pump Controlled Trial Serious IV med errors were frequent and could Serious IV med errors were frequent and could

be detected using smart pumpsbe detected using smart pumps However, no impact on the serious med error or However, no impact on the serious med error or

preventable ADE rate was foundpreventable ADE rate was found Likely because of poor design and also Likely because of poor design and also

compliancecompliance Behavioral and technologic factors must be Behavioral and technologic factors must be

addressed if smart pumps are to achieve their addressed if smart pumps are to achieve their potential for improving medication safety potential for improving medication safety

Rothschild et al, Crit Care Med 2005

Reporting and

SurveillanceTool

Safe Intravenous

Infusion Systems

Inpatient Psychiatric

Epidemiology Study

Ambulatory Pediatric

Epidemiology Study

Improving Safety in Nursing Homes

Organizational culture in promoting

patient safety

Dissemination Efforts (I) NewsletterNewsletter Website: Website: www.coesafety.bwh.harvard.eduwww.coesafety.bwh.harvard.edu Presentation of findings at national Presentation of findings at national

meetingsmeetings SGIM, AMIA, NPSF, NICHQ, SCCM, SGIM, AMIA, NPSF, NICHQ, SCCM,

Annual AHRQ Patient Safety ConferenceAnnual AHRQ Patient Safety Conference Harvard CME Course on Patient Safety Harvard CME Course on Patient Safety ITV Patient Safety SpecialITV Patient Safety Special

Dissemination Efforts (II) AHRQ WebcastAHRQ Webcast Dr. Bates, Gurwitz served on recent IOM Dr. Bates, Gurwitz served on recent IOM

CommitteeCommittee WHO WHO

Dr. Leape led drafting of WHO Dr. Leape led drafting of WHO Guidelines for Adverse Event Reporting Guidelines for Adverse Event Reporting and Learning systems and Learning systems

Dr. Bates leading development of global Dr. Bates leading development of global agenda for patient safety researchagenda for patient safety research

HIT-CERT Studies Automated telephone surveillance in outpatients Automated telephone surveillance in outpatients

prescribed specific medications to determine whether prescribed specific medications to determine whether or not they are experiencing specific ADEsor not they are experiencing specific ADEs

Evaluation of the impact of clinical decision support Evaluation of the impact of clinical decision support and automated telephone outreach on antihypertensive and automated telephone outreach on antihypertensive and lipid-lowering therapyand lipid-lowering therapy

Characterization of new errors with ambulatory Characterization of new errors with ambulatory electronic prescribingelectronic prescribing

Post-discharge ambulatory medication reconciliationPost-discharge ambulatory medication reconciliation Evaluation of multiple vendor-based electronic Evaluation of multiple vendor-based electronic

prescribing systems and health information exchange prescribing systems and health information exchange on outpatient medication safety in Mass and New on outpatient medication safety in Mass and New YorkYork

Identification with AMIA of a set of clinical decision Identification with AMIA of a set of clinical decision support rules that can be used in multiple settingssupport rules that can be used in multiple settings

Other Grants Study beginning supported by Pfizer to study Study beginning supported by Pfizer to study

automation of ambulatory adverse drug event automation of ambulatory adverse drug event reportingreporting

Study of safety climate in nursing homes Study of safety climate in nursing homes underwayunderway

Closing the loop on missed and delayed diagnosesClosing the loop on missed and delayed diagnoses Support to study role of pharmacists in the EDSupport to study role of pharmacists in the ED Study of the impact on safety of a chemotherapy Study of the impact on safety of a chemotherapy

robotrobot Study of impact of attending fatigue on error ratesStudy of impact of attending fatigue on error rates Study funded by Aetna looking at personalizing Study funded by Aetna looking at personalizing

breast cancer care based on genomic databreast cancer care based on genomic data Funding from WHO to assess global burden of Funding from WHO to assess global burden of

patient safetypatient safety

Massachusetts eHealth Collaborative

Effort to get all providers in state to use Effort to get all providers in state to use electronic recordselectronic records

Have given EHRs and set up clinical data Have given EHRs and set up clinical data exchange in 3 communitiesexchange in 3 communities

Evaluating impact on quality, safety, and Evaluating impact on quality, safety, and efficiencyefficiency

A potential model for rest of U.S.A potential model for rest of U.S.

Areas of Particular Interest Medication safetyMedication safety Surgical safetySurgical safety Nosocomial infectionsNosocomial infections Improving monitoringImproving monitoring

Of patientsOf patients Of devicesOf devices

Diagnostic errorDiagnostic error Using technology effectivelyUsing technology effectively Safety culture/organizational interestsSafety culture/organizational interests

Vision for Center BWH has long been leader in this areaBWH has long been leader in this area Multi-institutional, multi-disciplinary Multi-institutional, multi-disciplinary

programprogram Goal to bring together the best in this Goal to bring together the best in this

areaarea Provide core support, foster collaborationProvide core support, foster collaboration Already have many investigators working Already have many investigators working

in parallelin parallel Longitudinal focus is essential—problem is Longitudinal focus is essential—problem is

not going to go awaynot going to go away