Overview of AHRQ Resources to Improve Patient Safety (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Jeff Brady made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (3.5 MB) (Plugin Software Help).


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Overview of AHRQ Resources to Improve Patient Safety

September 15, 2009

 

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Agenda

  • Overview & Introduction
    • Jeff Brady, M.D., AHRQ, CQuIPS
  • Speakers
    • Erin Hartman, M.S., University of California, San Francisco
    • Jim Battles, Ph.D., AHRQ, CQuIPS
    • Greg Maynard, M.D., University of California, San Diego
    • Kerm Henriksen, Ph.D., AHRQ, CQuIPS
    • Farah Englert, AHRQ, OCKT

 

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To Err is Human:
Building a Safer Health System

  • 44,000—98,000 deaths/yr
  • 8th leading cause of death in US
  • National Costs: $17 to $29 billion
  • $2 billion Adverse Rx event costs alone
    • 2% hospital admissions (preventable)
    • Add $4,700 in costs to each hospitalization

Institute of Medicine, 1999

 

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Personal Experience with
Medical Errors

The percentage who said they have been personally involved in a situation where a preventable medical error was made in their own medical care or that of a family member?
(Source: Kaiser Family Foundation surveys)
 

 

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AHRQ's Mission

Improve the quality, safety, efficiency and effectiveness of health care for all Americans
 

 

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Patient Safety Portfolio

  • To improve the quality of care delivered to patients by decreasing or eliminating health care risks and harms.
    • Increased emphasis on implementation
    • Continued investment in research

 

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AHRQ
Core Business Areas

  • Creation of Knowledge
  • Synthesis and Dissemination
  • Implementation and Use

 

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AHRQ Patient Safety Budget

Budget figures for 2002, 2002, 2004, 2006, 2008, and 2010 (projected), in millions.
 

 

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Patient Safety Portfolio:
Broad Areas of Emphasis

  1. Create new knowledge about safe practices and optimal structure for care.
  2. Build research capacity by stabilizing upstream investment to keep the research pipeline flowing.
  3. Address methodological and core scientific questions—e.g., Evidence Report on Patient Safety Practices.
  4. Disseminate patient safety products effectively for implementation.
  5. Continue to engage in field-based partnerships (HAI ACTION)
  6. Seize opportunities for national implementation of safe practices

 

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AHRQ Patient Safety Resources

  • AHRQ PSNet
  • AHRQ WebM&M
  • TeamSTEPPST: Creating a safety Net for Healthcare Organization
  • TeamSTEPPST: Rapid Response System Module
  • Hospital Survey on Patient Safety Culture
  • Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report
  • Nursing Home Survey on Patient Safety Culture
  • Medical Office Survey on Patient Safety Culture
  • Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement

Continued..

 

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AHRQ Patient Safety Resources

  • Transforming Hospitals: Designing for Safety and Quality
  • Advances in Patient Safety: From Research to Implementation
  • Advances in Patient Safety: New Directions and Alternative Approaches
  • Patient Safety and Quality: An Evidence-Based Handbook for Nurses
  • Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety
  • 10 Patient Safety Tips for Hospitals
  • Guide for Developing Patient Safety Councils
  • Your Guide to Preventing and Treating Blood Clots
  • Blood Thinner Pills: Your Guide to Using Them Safely

PDF Version [ PDF file - 408.77 KB]

 

AHRQ Patient Safety Network (PSNet) and WebM&M

A world of patient safety information at your fingertips

 

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AHRQ Patient Safety Network (PSNet)

  • A national "one-stop" portal featuring a collection of resources and content about improving patient safety and preventing medical errors
  • Offers weekly updates of patient safety literature, news, tools, conferences, as well as wide variety of information on patient safety
  • Diverse users can customize the site around their unique interests by creating a "My PSNet" page
  • Web site: http://psnet.ahrq.gov

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AHRQ Patient Safety Network (PSNet)

Screen capture image of PSNet home page.

 

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AHRQ Patient Safety Network (PSNet) Search

Screen capture image of PSNet search page.

 

 

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Patient Safety Primers

Screen capture image of Patient Safety Primers.

 

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AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

  • Online journal featuring expert analysis of real medical error cases, perspectives on patient safety, and interviews with experts
  • Users submit cases of errors anonymously
  • Continuing education credit (CME/CEU) available
  • Web site: http://webmm.ahrq.gov

webmm.ahrq.gov

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webmm.ahrq.gov screenshot

 

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Evidence-based Team Training and Implementation Toolkit

  • Set of ready-to-use materials and training curricula to integrate teamwork principles
  • More than 900 people have been trained as TeamSTEPPS trainers as of July 2009
  • Collaboration between AHRQ and Department of Defense's military health system

http://teamstepps.ahrq.gov/

 

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TeamSTEPPS Rapid Response Module

  • Rapid Response Systems? composed of teams of clinicians who bring critical care expertise to patients requiring immediate treatment while under hospital care
  • Discusses how communication and teamwork strategies taught via TeamSTEPPS
    tools can work for Rapid Response
    Systems
  • CD includes:
    • PowerPoint presentations
    • Teaching modules
    • Video vignettes

AHRQ Publication No. 08(09)-0074-CD.

 

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AHRQ Suite of Patient Safety Culture Survey Tools

  • Suite of tools that measure patient safety culture in
    • Hospitals
    • Medical offices
    • Nursing homes
  • Tools include survey instruments and report templates
  • User's Guide provides information on
    • Getting started
    • Selecting a sample
    • Determining data collection methods
    • Establishing data collection procedures
    • Conducting a Web-based survey
    • Preparing and analyzing data
    • Producing reports

 

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Hospital Survey on Patient Safety Culture

 

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Hospital Culture Survey Comparative Database

  • Provides results hospitals can use as benchmarks in establishing a patient safety culture.
  • Features a narrative description of the survey findings, with results by hospital and respondent characteristics, as well as trending results for 98 hospitals that submitted data from previous and most recent safety culture surveys.
  • Appendixes provide data tables and show trends over time.

 

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Nursing Home Survey on
Patient Safety Culture

  • Pilot tested in 40 nursing homes
  • Survey materials and technical assistance for survey administration are free
  • Use the survey to:
    • Capture opinions of staff at all levels
    • Assess 12 domains of patient safety culture
    • Benchmark and evaluate patient safety efforts
    • Track changes in patient safety culture over time

 

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Medical Office Survey On Patient Safety Culture

  • Pilot tested in 200 offices
  • Free survey materials and technical assistance for survey administration
  • Designed for providers and staff in medical offices
  • Includes about 50 items in 12 areas (e.g.Teamwork, Staff Training)
  • Tracks changes in patient safety and evaluate interventions over time

 

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Guide Available for Deep Vein Thrombosis

  • Developed from Partnerships in Implementing Patient Safety program toolkit
  • Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals
  • Assists quality improvement practitioners in preventing one of the most important problems facing hospitalized patients — DVT / PE (VTE)

 

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Why build a toolkit for VTE Prevention?

Geerts WH, et al. Chest. 2008;133:381S-453S.
Cohen, Tapson, Bergmann, et al. ENDORSE study: Lancet 2008; 371: 387-94.
Surgeon General's Call to Action to Prevent DVT and PE 2008 DHHS
 

  • VTE is a common source of inpatient M&M
    • Jumbo jet crash / day- > Breast CA, HIV, MVA combined
    • May be # 1 preventable source of hospital death
  • Effective and safe methods of prevention exist
    • Large "implementation gap"—best practice? current practice
  • These methods are grossly underutilized
    • Awareness, difficulty implementing, no validated risk assessment
  • P4P, public reporting, and core measures

 

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To Achieve Improvement

SHM and AHRQ Guides on VTE Prevention
 

  • Real institutional support / prioritization
  • Will to standardize
  • Physician leadership
  • Measurement of process / outcomes
  • Protocol, integrated into order sets
  • Education
  • Continued refinement / tweaking- PDSA

 

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Hierarchy of Reliability

Level Predicted
Prophylaxis rate
1No protocol* ("State of Nature")40%
2Decision support exists but not linked to order writing, or prompts within orders but no decision support50%
3Protocol well-integrated
(into orders at point-of-care)
65-85%
4Protocol enhanced
(by other QI / high reliability strategies)
90%
5Oversights identified and addressed in real time95+%


* Protocol = standardized decision support, nested within an order set, i.e. what/when

 

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The Essential First Intervention

VTE Protocol

1) a standardized VTE risk assessment, linked to.
2) a menu of appropriate prophylaxis options, plus.
3) a list of contraindications to pharmacologic VTE prophylaxis

Challenges:

Make it easy to use ("automatic")
Make sure it captures almost all patients
Trade-off between guidance and ease of use / efficiency

 

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Example from UCSD Keep it Simple—A "3 bucket" model

LowMediumHigh
Ambulatory with no other risk factors. Same day or minor surgeryCHF
COPD / Pneumonia
Most Medical Patients
Most Gen Surg Patients
Everybody Else
Elective LE arthroplasty
Hip/pelvic fx
Acute SCI w/ paresis
Multiple major trauma
Abd / pelvic CA surgery
Early ambulation

UFH 5000 units q 8 h (5000 units q 12 h if > 75 or weight <50 kg)

LMWH
Enox 40 mg q day
Other LMWH
CONSIDER add IPC

Enox 30 mg q 12 h or
Enox 40 q day or
Other LMWH or

Fondaparinux 2.5 mg q day or
Warfarin INR 2-3
AND MUST HAVE IPC

 

 

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Map to Reach Level 3
Implementing an Effective VTE Prevention Protocol

  • Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis.
  • Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment)
  • Vette / Pilot—PDSA
  • Educate / consensus building
  • Place new standardized DVT order set 'module' into all pertinent admit, transfer, periop order sets.
  • Monitor, tweak—PDSA

 

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Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

33
Baseline
Consensus building
Order Set Implementation & Adjustment
Real time ID & intervention
N = 2,944 mean 82 audits / month
In press, JHM 2009
In press, Maynard, Morris et al, J Hosp Med
 

 

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UCSD—Decrease in Patients with Preventable HA VTE

 

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Hierarchy of Reliability

Level Predicted
Prophylaxis rate
1No protocol* ("State of Nature")40%
2Decision support exists but not linked to order writing, or prompts within orders but no decision support50%
3Protocol well-integrated
(into orders at point-of-care)
65-85%
4Protocol enhanced
(by other QI / high reliability strategies)
90%
5Oversights identified and addressed in real time95+%



* Protocol = standardized decision support, nested within an order set, i.e. what/when

 

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Map to Reach Level 5
95+ % prophylaxis

  • Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones:

    GREEN ZONE— on anticoagulation
    YELLOW ZONE— on mechanical prophylaxis only
    RED ZONE—on no prophylaxis

Act to move patients out of the RED!

 

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Situational Awareness and
Measure-vention: Getting to Level 5

  • Identify patients on no anticoagulation
  • Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications)
  • Contact MD if no anticoagulant in place and no obvious contraindication
    • Templated note, text page, etc
  • Need Administration to back up these interventions and make it clear that docs can not "shoot the messenger"

 

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Collaborative Efforts and Kudos

  • SHM VTE Prevention Collaborative I — 25 sites
  • SHM / VA Pilot Group — 6 sites
  • SHM / Cerner Pilot Group—6 sites
  • AHRQ / QIO (NY, IL, IA)— 60 sites
  • IHI Expedition to Prevent VTE—60 sites
  • SHM Team Improvement Award
  • NAPH Safety Net Award
  • Venous Disease Coalition

 

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AHRQ Simulation Grants

  • For research in 2007/2008 AHRQ sponsored 19 simulation grants for more than $10 million
  • 2-year cooperative agreements
  • Focused on practitioners and teams in a variety of clinical settings using a diverse range of simulation techniques
  • Intent was to inform researchers, providers, health educators, patients, policy makers, payers, and the public

 

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AHRQ's Grants—A Diverse Range of Simulated Clinical Applications

  • Central venous catheter insertion
  • High volume ambulatory surgical procedures
  • Diagnosis of melanoma
  • Obstetric emergency response drills in rural hospitals
  • Disclosure of medical error
  • Improving teamwork & culture of safety
  • Patient-tracking systems in the emergency department
  • Acute coronary syndrome management in rural setting
  • Medication administration
  • Rapid response emergency team training
  • Management of acute care events by graduate physicians
  • Airway management in the pediatric intensive care unit
  • Training rapid response teams
  • Emergent cesarean deliveries
  • Three-dimensional virtual reality team training
  • Patient care hand-offs
  • Post-anesthesia care unit communication
  • Pediatric emergency care
  • Resuscitation team response in small & rural hospitals

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Evidence Based Design

  • Build Private Rooms
  • Reduce Noise
  • Incorporate Nature
  • Improve Air Quality
  • Encourage Hand Hygiene
  • Improve Wayfinding
  • Reduce Walking Distance

 

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Transforming Hospitals: Designing for Safety and Quality

AHRQ Publication No. 07-0076-DVD
 

  • A DVD that demonstrates how evidence-based design can improve the quality and safety of hospital services while improving staff satisfaction and retention
  • Case studies of three hospitals illustrate the benefit of incorporating evidence-based design principles into new construction or renovation projects

 

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Advances in Patient Safety: From Research to Implementation

  • Four-volume set of 140 peer-reviewed articles representing an overview of patient safety studies

AHRQ Publication No. 05-0021-CD

 

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Advances in Patient Safety: New Directions and Alternative Approaches

  • Describes new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools to prevent harming patients
  • 4-volume set or 1 CD of 115 articles on reporting systems, risk assessment, safety culture, medical simulation, patient safety tools and practices, health information technology, medication safety, and more

AHRQ Publication No. 08-0034 (print copy)
or 08-0034-CD (Searchable CD-ROM)

 

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Handbook for Nurses

  • Comprehensive, 1400-page handbook for nurses on patient safety and quality.
  • Experts in the field reviewed the literature, and their contributions are grouped into sections that address:
    • Patient safety and quality
    • Evidence-based practice
    • Patient-centered care
    • Working conditions-work environment
    • Critical opportunities for patient safety and quality
    • Tools

AHRQ Publication No. 08-0043 (print copy) or 08-0043-CD (CD-ROM)

 

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Patient Safety Improvement Corps

  • DVD features a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level.
  • Modules address:
    • Investigation of medical errors and their root causes.
    • Identification, implementation, and evaluation of system-level interventions to address patient safety concerns.
    • Steps necessary to promote a culture of safety within a hospital or other health care facility.

AHRQ Publication No. 07-0035-DVD

 

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10 Patient Safety Tips for Hospitals

  • Evidence-based tips help hospitals promote patient safety
  • Go to: www.ahrq.gov/qual/10tips.pdf

 

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Guide for Developing Patient Safety Councils

  • Provides information and guidance to empower individuals and organizations to develop a community-based advisory council
  • Councils involve patients, consumers, and a variety of practitioners and professionals from health care and community organizations
  • Councils drive change for patient safety through education, collaboration, and consumer engagement

http://www.ahrq.gov/qual/advisorycouncil/

 

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Blood Clot Prevention

 

  • Deep vein thrombosis is a potentially deadly medical problem that affects at least 350,000 and possibly as many as 600,000 Americans each year
  • 24-page easy-to-read booklet in English and Spanish that helps both patients and their families:
    • Identify the causes and symptoms of dangerous blood clots.
    • Learn tips on how to prevent them.
    • Know what to expect during treatment.
  • Created by experts funded through AHRQ's Partnerships in Implementing Patient Safety grant program

 

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Blood Thinner Pills: Your Guide to Using Them Safely

www.ahrq.gov/consumer/btpills.htm
 

  • Consumer publication and DVD explain what to expect and watch out for while taking blood thinner pills
  • Based on research originally conducted by one of AHRQ's Partnership for Implementing Patient Safety grant projects
  • Educates patients about:
    • Medication therapy and potential side effects
    • How to communicate effectively with their health care providers
    • Tips for lifestyle modifications

 

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How to Order?

Ordering information for AHRQ Publications & Products available at http://www.ahrq.gov/news/pubsix.htm

Call the AHRQ Publication Clearinghouse at 1-800-358-9295

Send an E-mail to AHRQPubs@ahrq.hhs.gov
 

Current as of December 2009
Internet Citation: Overview of AHRQ Resources to Improve Patient Safety (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/brady/index.html