clinical practice: the only constant is change practice: the only constant is change brent c. james,...

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Clinical Practice: The Only Constant Is Change Brent C. James, M.D., M.Stat. Executive Director, Institute for Health Care Delivery Research Intermountain Health Care Salt Lake City, Utah, USA IHC ATP Alumni Conference 16th Annual IHI National Forum on Quality Improvement in Health Care World Center Marriott Resort & Convention Center, Orlando, Florida Monday, 13 December 2004, 6:00p - 9:00p

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Page 1: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Clinical Practice:The Only Constant Is Change

Brent C. James, M.D., M.Stat.Executive Director, Institute for Health Care Delivery ResearchIntermountain Health CareSalt Lake City, Utah, USA

IHC ATP Alumni Conference16th Annual IHI National Forum on Quality Improvement in Health Care

World Center Marriott Resort & Convention Center, Orlando, FloridaMonday, 13 December 2004, 6:00p - 9:00p

Page 2: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Dr. John Wennberg

Geography is destiny ("Who you see is what you get" *)

There is no health care "system"Supplier-induced demand:

Field of Dreams approach: Build it and they will comeJames T. Kirk: Do something, Bones! She's dying!Eddy: More is better -- if it might work, do itChassin: Enthusiasm for unproven methodsBoston City / Boston University Hospital, 1998:

Same housestaff on both servicesMore beds / easier access to resources on Boston University serviceBoston University readmit rate ~50% higher

* Richard Deyo, MD, MPH - in: Cherken, Deyo, Wheeler and Ciol. Physician variation in diagnostic testing for low back pain. Arth & Rheum 1994; 37(1):15-22 (Jan).

Page 3: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

American health care"gets it right"

54.9%of the time.

McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45 (June 26).

Page 4: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Medical injuries

Account for44,000 - 98,000 deaths per year

in the United StatesMore people die from medical injuries than from

breast cancer or AIDS or motor vehicle accidentsBrennan et al. New Engl J Med 1991 Thomas et al. 1999

Page 5: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Current health care

is the best the world has ever seenA few simple examples:

— From 1900 to 2000, average life expectancy at birthincreased from only 49 years to almost 80 years.

— Since 1960, age-adjusted mortality from heart disease (#1) has decreased by 56%; and (from 307.4 to 134.6 deaths / 100,000)

— Since 1950, age-adjusted mortality from stroke (#3) has decreased by 70%. (from 88.8 to 26.5 deaths / 100,000)

.

Initial life expectancy gains almost all resulted from public health initiatives -- clean water, safe food, and (especially) widespreadcontrol of epidemic infectious disease. But since about 1960, direct disease treatment has make increasingly large contributions.

Centers for Disease Control. Decline in deaths from heart disease and stroke--United States, 1900-1999. JAMA 1999; 282(8):724-6 (Aug 25).National Center for Health Statistics. Health, United States, 2000 with Adolescent Health Chartbook. Hyattsville, MD: U.S. Dept. of Health and Human Services, Center for Disease Control and Prevention, 2000; pg. 7 (DHHS Publication No. (PHS) 2000-1232-1).U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Government Printing Office, 1991 (DHHS Publication No. (PHS) 91-50212).

Page 6: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Medicine used to be simple, ineffective, and relatively safe.

Now it is complex, effective, and potentially dangerous.

Neal G. Reducing risks in the practice of hospital general medicine. In Clinical Risk Management, 2nd edition. British Medical Journal, 2001.

Chantler, Cyril. The role and education of doctors in the delivery of health care. Lancet 1999; 353:1178-81.

Sir Cyril Chantler

Page 7: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Are most failures unavoidable?

The price we pay(for)

diseases of medical progress

Barr, David. Hazards of modern diagnosis and therapy - the price we pay. JAMA 1955; 159(115):1452-6 (Dec 10)Moser, Robert H. Diseases of medical progress. N Engl J Med 1956; 255(13):606-14 (Sep 27)

Page 8: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Reasons for practice variation

ComplexityHow many factors can the human mind simultaneously

balance to optimize an outcome?"The complexity of modern American medicine exceeds

the capacity of the unaided human mind"

Lack of valid clinical knowledge (poor evidence)

-- Alan Morris, MD

-- David Eddy, MD

Reliance on subjective judgmentSubjective evaluation is notoriously poor across groups

or over time

Mark Chassin, MDEnthusiam for unproven methods ...If it might work, do it ...Quality = spare no expense ...

David Eddy, MD, PhD

Brent James, MD, MStat

Clinical uncertainty:

Page 9: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

The core assumption

"Our minds are interpreters of evidence. We can accurately convert all forms of evidence (formal evidence, observations, experiences, colleague's experiences) into conclusions, which in turn determine our actions."

"Therefore, no one has to tell us what to do. Just give us the evidence and we will figure it out. Besides, there are lots of other factors that need to be considered. This can only be done with clinical judgment."

Evidence Ourminds Conclusions Actions

Dr. David Eddy

Page 10: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

The core assumption is untenable

Poor evidence

The inherent complexity of modern medicine, versus the limitations of the human mind

Variations in beliefs

Variations in practices

High rates of inappropriate care

Dr. David Eddy

Page 11: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Other factors affect our decisions

Evidence Ourminds Conclusions Actions

Dr. David Eddy

Professional interestsFinancial interestsPersonal tastesDesire to have something to offerLove for the workWishful thinkingSelective memoryPressure from patients and familyLegal considerations

If our minds can't do the work very well, there are all sorts of other things to fill the void:

Huge ranges of uncertaintyLimited, complex Massive variation,inappropriate care

Page 12: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Protocols can improve care

A multidisciplinary team of health professionals -1. Select a high priority care process2. Generate an evidence-based "best practice" guideline3. Blend the guideline into the flow of clinical work

staffingtrainingsuppliesphysical layoutmeasurement / information floweducational materials

4. Use the guideline as a shared baseline, with clinicians free to vary based on individual patient needs

5. Measure, learn from, and (over time) eliminate variation arising from professionals; retain variation arising from patients ("mass customization")

Page 13: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

From craft-based practiceindividual physicians, working alonehandcraft a customized solution for each patientbased on a core ethical commitment to the patient andvast personal knowledge gained from training and

experience

To profession-based practicegroups of peers, treating similar patients in a shared settingplan coordinated care delivery processeswhich individual clinicians adapt to specific patient needs

(e.g., standing order sets)

(housestaff ::= apprentices)

early experience shows less expensiveless complexbetter patient outcomes

(facility can staff, train, supply an organize to a single core process)(which means fewer mistakes and dropped handoffs, less conflict)

The healing professions - and health care delivery -are changing ...

Page 14: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Idea 1

The solo practice of medicine is dead(at an intellectual, not necessarily an economic, level)

protocols as a common baselinemass customizationhigher productivity (a way to defend income)better patient outcomes (closing the quality gap)strong ties to electronic medical records

Page 15: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Issues for data automation

Principle: Automation must improve productivity;you can't destroy clinical work flow!

Issue 1: Paper vs. electronic storage

Issue 2: Free-text vs. encoded data

Page 16: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Four types of information

1. Sound data (e.g., recorded voice)

2. Image data (pictures, stored as rasterized pixel bitmaps; e.g.,a picture of a feature on a patient's skin;a digitized AP chest x-ray; or aa picture of a handwritten or typed medical note.)

4. Encoded data (multi-field "concepts" that computers can compare, interpret, etc.; required to do clinical decision support)

3. Free-text data standard word processor output;characters stored as codes, one per byte;even numbers are stored as characters;using ASCII codes (American Standard Code for

Information Interchange)

natural language

processing

optical character

recognition

computerized voice recognition

Page 17: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Clinical Data Repository (CDR)

relational data base management system

(rdbms)

EMPI -electronic master

patient index

VocSer -vocabulary server

PCMS(inpatient EMR)

Results Review Clinical

Workstation(outpatient EMR)

Pathology - laboratory - microbiology -surgical pathology

Pharmacy(operations)

Imaging - reports - images

Financial transactions

Inventory relief

EDW link - patient registries - outcomes reporting - etc.

Page 18: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Levels of data automation

2. Automation of lab - (encoded) clin path - microbiology - surgical path pharmacy - 3 national services, standard (encoded) formats

consultation reports - HL-7 formatted text

imaging - HL-7 formatted text (active research --> encoding)- digital image storage

3. The 'electronic file cabinet' - all electronic record (don't care about encoding)efficient data entry - dictation/transcription --> 'hot text,' voice recognitionefficient storage and retrieval across many care sitespractice operations support - telephone call support, lab results management

5. Level 2 encoding - focused condition-specific encoding

6. Level 3 encoding - fully encoded EMR, with text comments to customize

4.encoded problem list - automatic 'registries' for common chronic diseasesencoded medication list - first easy step in computerized order entryencoded allergy list

Level 1 encoding (assumes encoded patient demographics, pharmacy, and lab)

1.scheduling

Automation of billing encoded patientdemographics

message logsInfoButtonResults Reviewlab management

Page 19: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Implementing CW hot textAverage WRVUs per Day Average Patient Wait Time

Dr. Mark Shepherd, Bryner Clinic

21.323

24.1 24.323.2

24.523 23.6 23.4 23.7

31.2

21.9

16.7 16.9 16.915

16.9 16.9

14.7

17.2

QI, Q2 2

000

Q3 200

0Q4 2

000

Q1 200

1Q2 2

001

Q3 200

1Q4 2

001

Q1 200

2Apr 2

002

May 20

02

0

5

10

15

20

25

30

35

Ave

rage

Pat

ient

Wai

t Tim

e (m

inut

es)

0

5

10

15

20

25

30

35

Ave

rage

WR

VUs

per D

ay

Page 20: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Implementing CW hot text

Dr. Mark Shepherd, Bryner Clinic

293

369

299

349 337

371

335317

378

331 319342 343

420

358385

13531306

444402 405

286207

11021 10 0 0 1 0 0 0

Sep 99

Oct 99

Nov 99

Dec 99

Jan 00

Feb 00

Mar 00

Apr 00

May 00

Jun 00

Jul 0

0Aug 00Sep

00Oct

00Nov 0

0Dec

00

0

300

600

900

1200

1500

Tota

l Tra

nscr

iptio

n C

ost p

er M

onth

0

100

200

300

400

500

Tota

l WR

VUs

per M

onth

Total Transcription Cost per Month Total WRVUs per Month

Page 21: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Idea 2

EMRs are essential tools for the future(1) productivity enhancement; (2) protocol implementation

hard to implement (at present time)requires a relatively large organizationwe are in the era of the big systemsnational effort to (1) establish standards (HIPAA was just the beginning) and(2) drive EMR adoption (Regional Health Information Infrastructure)

Page 22: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Community acquired pneumonia

protocol protocol

"Outlier" (complication) DRG at discharge

15.3% 11.6%

In-hospital mortality

7.2% 5.3%

Relative resource units (RRUs) per case 55.9 49.0

Cost per case $5211 $4729

without with

24.7%

26.3%

12.3%

9.3%

p<0.001

p=0.015

p<0.001

p=0.002

Page 23: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Impact on net income

Improvement tocost structure

Payment mechanism

Decrease cost per unit

Decrease LOS (# nursing hours)

Decrease # of cases

Decrease # units per caseDecrease other units per

case

DiscountedFFS

(45%)

Per case

(40%)

Shared risk

(15%)

Per diem

(0%)

Page 24: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Impact on net income

Improvement tocost structure

Payment mechanism

Decrease cost per unit

Decrease LOS (# nursing hours)

Decrease # of cases

Decrease # units per caseDecrease other units per

case

DiscountedFFS

(45%)

Per case

(40%)

Shared risk

(15%)

Per diem

(0%)

Page 25: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Idea 3

Pay for performance (P4P):

one form of outcomes accountabilityrelies of performance measurement (technical problems)two main forms:- hit performance goal, get %-age payment increase- shared savings models

Page 26: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

High frequency injuries sources

1. Adverse drug events (ADEs, ADRs)

post-operative deep wound infectionsurinary tract infections (UTI)lower respiratory infections (pneumonia or bronchitis)bacteremias and septicemias

2. Iatrogenic infections

4. Mechanical device failures3. Pressure injuries

5. Complications of central and peripheral venous lines

6. Deep venous thrombosis (DVT) / pulmonary embolism (PE)

7. Strength, agility and cognition (injuries and restraints)

8. Blood product transfusion

9. Patient transitions

Page 27: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Detecting Adverse Drug Events

# of ADEs / %(# per

annum)

Total ADEs

Nurse Incidence Reporting

"Enhanced" Reporting

HELP System

Moderate and severe

ADEs

9 / 0.025%(6)

91 / 0.25%(60)

731 / 2.0%(487)

701 / 1.9%(467)

Page 28: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Simple criteria for detecting ADEs

use of naloxoneuse of benadryluse of inapsineuse of lomotilnurse reports of rash/itchinguse of loperamidetest for c. deficile toxindigoxin level > 2abrupt med stop or reductionuse of vitamin Kdoubling of blood creatinineuse of kaopectateuse of paregoricuse of flumazenil

pharmacypharmacypharmacypharmacynurse reportingpharmacyclinical labclinical labpharmacypharmacyclinical labpharmacypharmacypharmacy

21.9 28.3 28.321.0 20.8 49.139.2 20.4 69.526.8 8.5 77.017.9 5.1 82.122.3 3.4 85.524.3 3.1 88.6 2.3 2.2 90.848.0 1.0 91.8 4.8 0.9 92.7 0.4 0.8 93.521.8 0.7 94.2 9.8 0.7 95.077.3 0.7 95.7

1.2.3.4.5.6.7.8.9.

10.11.12.13.14.

Detection criterion Location Rate (%)Positive

True

DetectedAll ADEs

% of

Total (%)Cumulative

(case finding through "concurrent clinical triggers")

Page 29: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Utah-Missouri study (AHRQ)

Identified and validated ICD-9 Patient Safety Code set (~1,000 codes)

Mined hospital discharge abstracts to identify charts for review (verified acceptable positive predictive value)

Found numbers of verified injuries similar to those discovered by concurrent trigger tools (including serious outpatient events that result in hospitalization)

Very little overlap with concurrent trigger methods: ICD-9 codes appear to capture a different universe of events

(case finding through "retrospective code triggers")

Page 30: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

LDS Hospital, 2001

ICD9-CM total code hits = 1574(973 unique)

concurrent trigger total hits = ~2460(~1950 unique)

(major advantage: can intervene and abort harm)

pharmacist verified ADEs from concurrent triggers = 258

(168 unique)

511unique

90unique

200 charts in random sample- 13 charts couldn't be found (6.5%) 187 charts reviewed

10 coding errors ( 5%) 24 not ADEs (false positives) (13%) 51 outpatient poisonings and suicides (27%) 59 outpatient ADEs (32%) 43 inpatient ADEs (true positives) (23%) (1484 x 0.230 = 341 unique inpatient ADEs)

Final estimates: 341 ADEs detected by ICD-9 codes alone 90 ADEs detected by both systems 168 ADEs detected by concurrent triggers alone

599 total ADEs detected (43.1% of final total detected by concurrent triggers alone)

Xu W, Hougland P, Pickard S, et al. Detecting adverse drug events using ICD-9-CM codes. Poster presentation, AHRQ 2nd Annual Patient Safety Research Conference, Arlington, Virginia, 3 March 2003.

random sampleof 200 encounters(from 1484 cases)

Page 31: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Tracking injuries

Current (voluntary reporting) systems miss the vast majority of injuries (finding only 1 in 100-150 injuries)

Most often (e.g., >80% of the time for ADEs), clinical teams don’t associate patient symptoms with the treatments that are causing them

A more accurate perception of sources of injury can hugely change intervention strategies

Page 32: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Injury and near miss detection

- case finding - evaluation - classification

Epidemiologic analyses

- new taxonomies

Process Analyses - FMEA - HACCP - other related methods

Successful change ideas from the medical literature, other health care organizations, and other industries

Possible system fixes that could improve safety results

- hypotheses for process change - explicit process models very useful

Prioritization (is this event an epidemic?)

Rapid Cycle Testing often with heavy reliance on

intermediate outcomes (process measures)

Holding the Gains Monitor final outcomes (i.e., injury rates) and

intermediate process outcomes

Deployment and Implementation

Patient Safety: Achieving a New Standard for Care. Edited by Aspden P, Corrigan JM, Wolcott J, and Erickson SM. Washington, DC: National Academy Press, 2004. Figure 5, pg. 179.

Page 33: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Detecting patient safety events

1. Case finding (based on explicit criteria)

2. Evaluation (based on explicit criteria)

3. Classification (based on explicit criteria)

Externaldata system

audit

Page 34: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Case finding

Common eventsAdverse drug eventsIatrogenic infectionsPressure injuryMechanical device failuresVenous linesVTETransfusionsPatient fallsPatient transitions

Rare events "Wrong" surgeryKidnappingSuicide - etc. -

Concurrent(data-based)

trigger systemsLDSH / B&W

CDC infection controlx

LDSHxxx

B&Wx

Abstract (ICD-9)(data-based)

trigger systemsUtah-Missouri (AHRQ)

xx

LDSHxxxxx

Criteria-basedmanual systems

(e.g, QaRNS, JCAHO SE,NQF "Never Events")

Relatively poor event detection

rates

Current most

effective method

Voluntaryreporting(in a Culture

of Safety)

Relatively poor event detection

rates

Current most

effective method

Retrospective Chart Review

Page 35: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Preventable causes of ADEs

PhysiologicFactors

PharmocologicFactors

Drug Administration

Errors

Ordering Errors

Transcribing

Spelling

HemalRenal

Dilution

Time

Nurse

Route

Rate

ADE

NursePhysician

Pharmacist

PhysicianPharmacy

Nurse/Clerk

PharmacistPatient

PhysicianDietician

Physician

Wrong Drug

Dose

Scheduling

Dosage

Route

Past Allergic Reaction

Absorption

WeightAge

Gender

Electrolyte

Hepatic

RaceBrand Name vs. Generic

Drugs

Expected

Drug/Drug

Unforeseen

Drug/Food

Drug/Lab

Neural

Psychic

Compliance

Patient

OrderMissed

Page 36: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Causes of Adverse Drug Events

0

10

20

30

40

50

60

70

80

90

100

Per c

ent

Causes

Page 37: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Causes of Adverse Drug Events

Class % Description Avoidable?

?28.0PharmExpected

Known drug reactions

Yes23.0 Failure to adjust for decreased renalfunction

PhysioRenal

Yes14.2 Failure to adjust for patient agePhysioAge

Yes5.7 Failure to adjust for patient body massPhysioWeight

Yes5.0 Error in dosage on orderOrderDosage

Yes4.6 Failure to adjust for known hematologicfactors

PhysioHemal

Totalpreventable 66.2

Page 38: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Medication errors vs. ADEs

Prospective daily surveillance of 202,222 inpatients for theoccurrence of medication errors and adverse drug events

Medicationerrors

n = 4155

Adverse drugevents

n = 3996

n = 138

Definition of medication errors: Assumes that the physician orders correctly,but that the pharmacist then prepares the medication incorrectly, or that the

nurse delivers it incorrectly. Specifically, (1) wrong preparation, (2) wrong dose,(3) wrong route of delivery, (4) wrong rate of delivery, and/or (5) wrong patient.

Page 39: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Attack injuries, not errors

What is classified as an "error "derives from what is judged to be "preventable; "

but, at this stage, those (subjective) judgmentsmay be perverted by the "name, shame, and blame game," and seriously misinformed .

It is more useful to think in terms of"medical injuries" rather than "errors."

Page 40: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

ADEs at LDS Hospital

233

581 567 569 567

437

477

355

271 271 280

89 90 91 92 93 94 95 96 97 98 99(3)

Year

0

100

200

300

400

500

600

0

100

200

300

400

500

600

Tota

l # m

oder

ate

+ se

vere

AD

Es

Page 41: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Prophylactic antibiotics on time

10.14 9.8910.19

8.92 8.75

7.867.53

8.83 8.748.11

3.19

7.18

3.2

5.44

4.64

Q1 199

9 Q2 Q3 Q4Q1 2

000 Q2 Q3 Q4

Q1 200

1 Q2 Q3 Q4Q1 2

002 Q2 Q3

0

2

4

6

8

10

12

Org

an s

pace

& d

eep

infe

ctio

ns p

er 1

000

0

2

4

6

8

10

12

n = 9767 9519 9869 9713 9799 10093 9743 9951 10117 9407 9612 93779104 9737 9700

8.97

5.33

Page 42: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Idea 4

An expanded nationalfocus on patient safety

standardized data systemsindependent, external auditdetected injury rates much higher than todaydrive for substantial systems-level change

Page 43: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

ICU admissions by weeks gestation

6.66

3.36

2.47 2.65

3.44

4.26

37 38 39 40 41 42

Weeks gestation

0

2

4

6

8

10

Perc

ent N

ICU

adm

issi

ons

0

2

4

6

8

10

Deliveries w/o Complications, 2002 - 2003

8,001 18,988 33,185 19,601 4,505 258n =

Page 44: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

RDS by weeks gestation

1.19

0.47

0.25 0.3

0.470.39

1.92

0.68

0.42 0.41

0.670.78

37 38 39 40 41 42

Weeks gestation

0

0.5

1

1.5

2

2.5

Perc

ent

0

0.5

1

1.5

2

2.5

Deliveries w/o Complications, 2002 - 2003

8,001 18,988 33,185 19,601 4,505 258n =

Page 45: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Elective inductions <39 weeks

5.5 5.1

6.6 6.3 65.3

8.2

5.4 5.76.6 6.6

7.9

6.4

7.6 7.6

4.63.5

4.55

26.726.9

29 29.2

25.3

27.6

20.4

19.1

16.5

15.2

8.4

10.7

8.1

6.85.9 6.1 6

5.1

6.3

Jan 01 Mar May Ju

lSep Nov

Jan 02 Mar May Ju

l

Jan 03 Mar May Ju

lSep Nov

Jan 04 Mar May Ju

l

0

5

10

15

20

25

30

% e

lect

ive

indu

ctio

ns <

39

wee

ks

0

5

10

15

20

25

30

382372

490415

430435

422455

430382

356337

372366

455n = 423453

473476 512

475602

557667

564637

578541

573533

505501

474536

562545

535500

Page 46: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Unplanned c-section rates

3331.4

36.1

28.3

17.7

15.1

17.6

14.4 14.3

5.84.5

2.1

0

20

8.2 8.5

3.6 3.4 3.93.2

2.41.1 0.9 1

0 0

1 2 3 4 5 6 7 8 9 10 11 12 13

Bishop score

0

5

10

15

20

25

30

35

40

Perc

ent c

-sec

tions

0

5

10

15

20

25

30

35

40

Electively induced patients by Bishop score, Jan 2002 - Aug 2003

10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7

MultipsPrimips

n

Page 47: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Average hours in labor & delivery

22.1

20.7

17.4

15.715

13.8

12.611.6

10.4

9 9

7.58.2

12.4 12

10.810.1

9.2

8.17.6

7.16.4

5.9 5.5 5.14.1

1 2 3 4 5 6 7 8 9 10 11 12 13

Bishop score

0

5

10

15

20

25

Hou

rs

0

5

10

15

20

25

Electively induced patients by Bishop score, Jan 2002 - Aug 2003

10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7

MultipsPrimips

n

Page 48: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Primiparous elective inductions

15.314

15.3 14.5 14.7

11.612.8

11.8 12.6 12.8

15.1

12.1

9.98.8

6.8 6.5 6 6.1

53 53

63

5357

45

5652

41

52

62

4649

35

21 2126 28

110

87

119

109

124

91

107

94100

105

118

8781

67

57 57

4652

Jan 20

03 Feb Mar AprMay Ju

n Jul

Aug

Sep OctNov

DecJa

n 2004 Feb Mar Apr

May Jun

0

20

40

60

80

100

120

140

Num

ber o

f pat

ient

s

0

10

20

30

40

50

% o

f all

prim

ipar

ous

deliv

erie

s

Bishop's score < 10Bishop's score < 8Goal: Reduce "inappropriate" nullip inductions by 50%

Page 49: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Labor & delivery variable cost

Jan 20

03 Feb Mar Apr

May Jun Jul

Aug

Sep Oct

Nov

DecJa

n 2004 Feb Mar Apr

May

1000

1200

1400

1600

1800

2000

Ave

rage

com

bine

d va

riabl

e co

st ($

)

1000

1200

1400

1600

1800

2000

Expected maternal and fetal combined variable costGoal: hold increase to no more than 6.85%Actual combined variable cost

Page 50: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Well newborn bilirubin testing

Mar 20

01 May Jul

Sep NovJa

n 2002 Mar May Ju

lSep Nov

Jan 20

03 Mar May Jul

Sep NovJa

n 2004 Mar May

0

20

40

60

80

100

% te

sted

0

20

40

60

80

100

Newborns >= 35 weeks gestation seen in Well Newborn Nursery (excluding hospitals using Bilicheck testing)

Page 51: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

0

5

10

15

20

25

0 12 24 36 48 60 72 84 96 108 120

Hour-Specific Bilirubin Risk Chart for Term & Near-Term InfantsAdapted and revised [April 2003] based on IHC data (12-54h) & from Bhutani VK et al. Pediatr 1999; 103:6-14 & J Perinat 2001; 21:S76-S82 (72-120h)

Neo

nata

l Ser

um B

iliru

bin

(mg/

dL)

Age (h)

NSB in 48h†

High Risk Zone

Low Risk Zone

Low Intermediate Risk Zone

High Intermediate Risk ZoneConsider Phototherapy if Premature or

Evidence of hemolysis

95th percentile

75th percentile

40th percentile

NSB in 24h†

Phototherapy & NSB in 6-12h†

NSB >25: Neonatology Phone Consult; Consider Exchange Transfusion in the Healthy Term InfantNSB >20: Consider Exchange Transfusion in the Hemolytic Term Infant or Healthy Near-Term Infant

Risk FactorsJaundice in the first 24hVisible jaundice before dischargePrevious jaundiced siblingGestation < 38 weeksExclusive breastfeedingEast Asian raceBruising, cephalohematomaMaternal age > 25yMale sex

† A TcB may be substituted for NSB. Near exchange levels, a NSB is preferred. NSB = Neonatal serum bilirubin; TcB = transcutaneous bilirubin

Page 52: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Newborns w/ hyperbilirubinemia

01

20

3 3

0

3

02 2

3

02

12 2

12

1 1 12

01

02

13

0 0 01

01 1

0 0 0 0

2826

27

37

26

32

24

34

30

16

34

19

28

2224

2627

3234

31

25

1716

14

27

20

1415

1315

10

1315

12

1615

10

21

13

16

Mar 20

01 May Jul

Sep NovJa

n 2002 Mar May Ju

lSep Nov

Jan 20

03 Mar May Jul

Sep NovJa

n 2004 Mar May

0

10

20

30

40

50

Num

ber o

f pat

ient

s

0

10

20

30

40

50

Bilirubin > 19.9 mg/dLBilirubin > 25 mg/dL

Page 53: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

Hyperbilirubinemia readmissions

0.061

0.039

0.034

0.073

0.0470.044

0.027

0.036

0.022

0.041

0.035

0.071

0.044

0.081

0.043

0.027

0.036

0.0450.048

0.062

0.0350.036

0.049

0.019

0.0330.0290.029

0.034

0.022

0.045

0.0220.0230.02

0.044

0.024

0.012

0.018

0.025

0.017

0.009

0.014

0.0090.009

0.02

0.0140.01

0.0260.0220.023

0.021

0.008

0.019

0.008

0.0160.014

Jan 0

0

Apr Jul

OctJa

n 01

Apr Jul

OctJa

n 02

Apr Jul

OctJa

n 03

Apr Jul

OctJa

n 04

Apr Jul

0

0.02

0.04

0.06

0.08

0.1

Prop

ortio

n re

adm

itted

0

0.02

0.04

0.06

0.08

0.1

Page 54: Clinical Practice: The Only Constant Is Change Practice: The Only Constant Is Change Brent C. James, ... To profession-based practice ... efficient data entry - dictation/transcription

"I am sorry for you, young men (and women) of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation."

At the opening of the Phipps Clinic in England, near the end of his career. Cited in

-- Sir William Osler

Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).