09/24/2012

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The “Cost” of Harm

Sharon Anderson, RN, BSN, MS, FACHE

Economic

Healthcare Staff

Patients and Families

True “Cost” of Harm

What would 99.9% reliability mean in other areas?

An error rate of only .1% =

1 hour of unsafe drinking water every month

2 unsafe plane landings per day at O’Hare Airport in Chicago

16,000 pieces of mail lost every hour

22,000 checks deducted from the wrong bank account each hour

In Quality Terms,

Hospitals Typically Have only 96-98% Reliability

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To err is human…….

Nationally, broader

concepts emerging

Historical focus has

been on error –

voluntary/subjective

New Thinking –

“Harm” or adverse

events

Errors

New Patient Safety Focus

Harm

Primum non Nocere…..

Latin phrase that means:

"First, do no harm".

Hippocratic Corpus: "The physician must...have two special objects in view with regard to disease, namely, to do

good or to do no harm"

Concept of Medical Harm……

The term "medical harm“

first used after a Harvard Medical study in 1991

concluded that patients incurred a substantial

amount of injury from medical management, and

the injuries were a result of substandard care

A 1999 report by the Institute of Medicine, “To Err is

Human,” further defined the scope of the problem and

outlined comprehensive recommendations for

reducing harm.

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Medical Harm

What is the definition of ‘harm”?

Institute for Healthcare Improvement (IHI) definition:

The unintended physical injury resulting from or contributed

to by medical care (including the absence of indicated

medical treatment), that requires additional monitoring,

treatment or hospitalization, or that results in death.

Such injury is considered harm whether or not it is

considered preventable, whether or not it resulted from

a medical error.

Error

Medication dose ordered correctly, wrong dose administered.

Surgery performed on the wrong side.

Sponge left in during a procedure.

Adverse Events (Harm)

Pneumonia developed while on a patient is on a ventilator.

Diabetic patient develops a wound infection after surgery.

Blood clot develops in a patient’s leg while on bedrest.

Examples

Medical Error/Harm

Where:

Hospitals

Physician Offices

Nursing Homes

Pharmacies

Urgent Care Centers

Home Care

Who:

Physicians

Nurses

Pharmacist

Ancillary Staff

Laboratories

Medical Device Companies

Drug Companies

Economic

True “Cost” of Harm in Healthcare

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National Level

The IOM report estimates that medical errors

cost the Nation approximately $37.6 billion

each year; about $17 billion of those costs are

associated with preventable errors.

About half of the expenditures for preventable

medical errors are for direct health care costs

(IOM, 1999).

Christiana Cares’s Calculation of

“Cost Impact of Harm”

Determined by identifying the difference in the cost of care for patients with a particular type of harm compared to similar patients without harm to see the difference in cost. (additional LOS, ICU, tests, treatments)

Ventilator associated pneumonia (VAP) $45,712

Blood stream infections (BSI) $18,079

Urinary tract infections $2,500

MRSA $ 6,344

C-difficile $13,613

Patient Falls (with major injury) $ 5,903

Hospital Acquired Pressure Ulcers (stage 3 or 4) $ 9,022

Note: These estimates are also supported in safety literature.

To achieve this vision, CMS is committed to care that is safe, effective, timely, patient-centered, efficient, and equitable.

Beginning October 2008 CMS targeted specific conditions that if they were diagnosed and not identified as “present on admission” would assume to be hospital acquired and payment would be reduced.

CMS is using a subset of the National Quality Forum’s 28 “Never Events” as the foundation for the Hospital Acquired Conditions and Present on Admission Program.

CMS Vision for Healthcare

Quality “The right care for every person every time”

1% of the Medicare base DRG payment

(increasing to 2% by 2017) will be withheld to form

a pool

Christiana Care’s contribution is about

$2,000,000

The pool will be distributed back to hospitals

based attainment or improvement in the

measures, compared to other hospitals nationally

Value Based Purchasing

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Effective with July 2011 discharges:

Performance scores based on attainment and improvement

12 process of care measures (core measures) 70%

Patient Experience of Care Survey (HCAHPS) 30%

Future (FY2014) – Outcome measures added

30-Day Mortality (AMI, Heart Failure, Pneumonia)

Next Steps

Hospital acquired conditions (Never Events)

AHRQ Patient Safety & Quality Indicator Composites

Medicare spending per beneficiary

Value Based Purchasing 30-Day Mortality (Medicare, Risk Adjusted)

Acute Myocardial Infarction

Heart Failure

Pneumonia

Hospital Acquired Conditions (Medicare)

Foreign object retained after surgery

Air embolism

Blood incompatibility

Pressure ulcer stages III & IV

Falls & Trauma

Vascular catheter-associated infections

Catheter-associated urinary tract infection

Manifestations of poor glycemic control

AHRQ Patient Safety & Inpatient Quality

Indicators (Medicare)

Complication/patient safety for selected

indicators (composite)

Mortality for selected medical conditions

(composite)

Value Based Purchasing – By FY 2014

Medicare spending per Beneficiary:

Hospital average / National Median

AMI: Fibrinolytic Therapy

within 30 minutes

AMI: Primary PCI within 90

minutes

HF: Discharge Instructions

PN: Initial Antibiotic Selection

PN: Blood Culture before 1st

Antibiotic

SCIP: Prophylactic antibiotic

within 1 hr of incision

SCIP: Prophylactic antibiotic

selection

SCIP: Prophylactic antibiotic

discontinued within 24 hrs

SCIP: Post-op serum glucose

control (cardiac surg)

SCIP: Periop beta blockers (pts

on BB prior)

SCIP: VTE prophylaxis ordererd

SCIP: VTE prophylaxis received

24 hr pre/post

Nurse Communication

Doctor Communication

Hospital Staff

Responsiveness

Pain Management

Medication Communication

Hospital Cleanliness &

Quietness

Discharge Information

Overall Hospital Rating

Foreign Object Left in Surgery

Air Embolism Blood Incompatibility Stage III and IV Pressure

Ulcers Falls with Trauma Manifestations of Poor

Glycemic Control Catheter-Associated

Urinary Tract Infection

Vascular Catheter-Associated Infection

Deep Vein Thrombosis Joint Replacement

Surgical Site Infection

CABG (Mediastinitis) Laparoscopic Gastric

Procedures Orthopedic Procedures (Spine,

Neck, Shoulder, Elbow)

Never Events Chosen for Hospital Acquired Conditions Program

These conditions will reduce payment if they are the only complication or comorbid condition during the patient’s stay: Hospitals will be penalized for higher than expected 30-day

readmission rates. Initial focus: Heart Failure Acute Myocardial Infarction Pneumonia

Followed by: COPD Coronary Bypass Grafting Percutaneous Coronary Interventions Vascular Procedures

Medicare payments (1% in FY2013 up to 3% in FY2015) will be withheld for high rates

Value Based Purchasing: Readmissions

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Healthcare Staff

True “Cost” of Harm in Healthcare

“Second Victim”

Healthcare Provider – often the “second

victim” and experience significant

emotional distress following serious

errors and near misses.

66%

51%

48%

48%

15%

56%

36%

34%

33%

9%

51%

31%

32%

34%

10%

0% 20% 40% 60% 80% 100%

Increased Anxiety about Future Errors

Decreased Job Confidence

Decreased Job Satisfaction

Increased Sleeplessness

Harm to Prefossion Reputation

% Reported Error-Related Impact

Domains by Level of Error Severity

Serious Error

Minor Error

Near Miss

Waterman, A et al, The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada, Joint Commission Journal on Quality and Patient Safety, Aug 2007 Vol 33 No 8

Story:

Kimberly Hiatt, RN

State Nursing Commission

imposed $3,000 fine, 80

hours of new course work on

medication administration

and 4 years of probation

Kim committed suicide on

April 4th at the age of 50.

September 14, 2011 she recognized that she overdosed a fragile baby in the Cardiac ICU at Seattle Children’s Hospital.

She gave 10 times the intended dose of calcium chloride (1.4 grams versus 140 miligrams) exacerbating her cardiac condition which contributed to the death of 8 month old Kala Zautner.

Hiatt was escorted from the hospital after her mistake, immediately put on administrative leave, then fired. She was devastated.

Picture & Story - MSNBC

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6 Stages of Recovery

University of Missouri Health System

S.D. Scott, Office of Clinical Effectiveness

Stage 1: Chaos and Accident Response – Immediately clinicians describe chaotic and confusing scenarios when they realize what has occurred. External and internal turmoil.

Stage 2: Intrusive Reflections – Period of haunted re-enactments with feelings of internal inadequacy and self-isolations. “What if” questions…..

Stage 3: Restoring Personal Integrity – Seeking support from a trusted individual.

Stage 4: Enduring the Inquisition – After the initial focus of stabilizing the patient concern as to how the institution will react and concern about repercussions affecting job security, licensure and litigation.

Stage 5: Obtaining Emotional First Aid – Seeking longer term emotional support – coworkers, professionals, loved ones.

Stage 6: Moving on, dropping out, surviving or thriving.

The single greatest impediment to

error prevention in the medical

industry is “that we punish people for

making mistakes.”

Dr. Lucian Leape

Professor, Harvard School of Public

HealthTestimony before Congress on

Health Care Quality Improvement

“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is

to blame the people involved. If we find out who made the errors and punish them, we solve the

problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system

and the problems will continue.”

Don Norman

Author, the Design of Everyday Things

56%

42%

3%

Partial Disclosure

(mention adverse

Event but not error)

Full Disclosure

(explicit statement

that error occurred)

No Disclosure

(no reference to

adverse event or

error)

0 0

10

20

30

40

50

60

Perc

en

t o

f p

hysic

ian

s a

gre

ein

g

What physicians would

disclose about error

Source: Gallagher TH – Choosing your words carefully: how physicians would disclose harmful

medical errors to patients. Arch Intern Med. 2006; 166: 1585-1593

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29

The Foundation of a Strong

Culture

Learning is valued at every level

By learning from errors, we are able to identify solutions

Open and fair: Employees can admit mistakes and will be treated fairly

Balance of accountability between system and individual

Safe systems give employees the best opportunity to get the job done right the first time

Management of behavioral choices

30 30

MANAGE

BEHAVIORAL

CHOICES

DESIGN SAFE

SYSTEMS

ADVANCE OUR

LEARNING

CULTURE

PROMOTE AN

OPEN AND

FAIR CULTURE

Leaders are responsible for designing and implementing

systems that support the safe choices of healthcare workers

Healthcare workers are responsible for the quality of their choices

Cornerstones of Just Culture

The Three Behaviors

Reckless

Behavior

Conscious disregard of

unreasonable risk

Manage through:

• Disciplinary action

At-Risk

Behavior

A choice: risk not

recognized or believed

justified

Manage through:

• Removing incentives for

at-risk behaviors

• Creating incentives for

healthy behaviors

• Increasing situational

awareness

Human

Error

Inadvertent action: slip,

lapse, mistake

Manage through changes in:

• Processes

• Procedures

• Training

• Design

• Environment

• Choices

Console Coach Discipline

Patients and Families

True “Cost” of Harm in Healthcare

09/24/2012

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Estimated Harm Due to Error

As many as 1 out of every 25 hospital patients (4% of hospitalizations) suffer from a preventable injury due to error (AHRQ, 2000).

About one in seven Medicare hospital patients experiences harm from medical care. Another one in seven experienced temporary harm because the problem was caught in time and reversed. (Department of Health and Human Services report, 2008

Approximately 1.14 million total patient safety incidents occurred among the 37 million hospitalizations in the Medicare population from 2000 through 2002 – 3.1% of hospitalizations (HealthGrades, 2004).

At least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications, the influential Institute of Medicine concluded in a major report (Washington Post, 2006).

Adverse events (of any kind) occur in 4% to 14% of all admissions. 50% to 70% are due to preventable error. (JAMA, 2009)

Estimated Deaths Due to Error

At least 44,000 or as many as 98,000 people die in hospitals each year (IOM Report 1999 “To Err is Human”

195,000 Americans die a year due to preventable errors (HealthGrades, 2004)

An estimated 15,000 Medicare patients die each month in part because of care they receive in the hospital, - 44% of these were deemed preventable errors (Department of Health and Human Services report, 2008,

99,000 patients die as a result of hospital-acquired infections (HAI) each year (AHRQ, 2009).

About 7,000 people per year are estimated to die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries (Kaiser Family Foundation).

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