Collaborative Healthcare Patient Safety Organization Eliminating preventable harm and improving the quality of health care delivery ■ A DIVISION OF THE HOSPITAL QUALITY INSTITUTE ABOUT US CHPSO Mission WA ND MN OR Eliminating WI preventable IA NE NV OH harm and CO CA KS improving the KY TN AZ quality of NM AR GA health care TX delivery. HW CHPSO Vision CHPSO Membership remained steady in 2019 with more than 450 members in 13 states: Arkansas, CHPSO’s members Arizona, California, Georgia, Hawaii, Iowa, New Mexico, Nevada, Ohio, Oregon, Tennessee, Texas will lead the nation in and Washington. A total of 93 new facilities/organizations from seven states are pending or in progress. These members contributed to a growing database of more than 2.5 million safety events. providing the safest and highest quality Participate health care CHPSO works with members to facilitate and streamline the data submission process. CHPSO partners with NextPlane Solutions to allow members to connect to the CHPSO database, saving hospitals the cost of specialized solutions. With NextPlane Solutions, members can generate an Excel spreadsheet or plain text report delimited by commas or other characters. The entire process, including taxonomy mapping, generally takes up to three hours for the initial submission. For more information, contact CHPSO at [email protected] or visit our website, www.chpso.org. Benefits y Patient Safety Work Product y Event feedback and consultation (PSWP) privilege y Educational webinars y Collaborate and problem solve y Alerts and quarterly newsletters with other providers y Legal counsel discussion group y Periodic safety event evaluations y Job board y Bi-weekly Safe Table meetings y Custom research requests EVENT REPORTS MEDICATIONS 2019 events by category Medication Safety Event Report Analysis Other/Uncategorized The CHPSO database Overview of events in the dataset. For example, a case involving delays had 2.5 million reports by the end of 2019. Nearly in care and access to appropriate medication for a child with Medication or Other Substance “Event Type” — Data Element 21 in the Agency for Healthcare 605,000 reports were a Tylenol overdose awaiting an airlift transport contained submitted to CHPSO in Research and Quality (AHRQ) Common Formats for event Surgery or Anesthesia 2019. We continue to elements related to availability of medications, automated (includes invasive procedure) reporting — represents the primary classification for each share trends and lessons safety event report. Currently, this field can have values for dispensing cabinets, communication issues, and the mention Fall learned among our community. the following categories: of the relevant medications (e.g., acetaminophen and ace- Pressure Ulcer CHPSO Database: “Other/ tylcysteine). Likewise, a case related to a dosing error of a Uncategorized” includes Device or Medical/Surgical Supply, y vasoconstrictor used to treat life-threatening hypotension events not covered by the Blood or Blood Products including Health Information Technology (HIT) standard categories such (often in the setting of septic shock) contained elements y Perinatal as laboratory and radiology. Device/Medical Surgical Supplies related to an overdose, the programing of the infusion pump, Device reports include Health Information y a reference to barcode medication administration (BCMA) Healthcare-associated Infection Falls Technology (HIT). technology, a comment regarding the facility’s electronic y Blood or Blood Product Healthcare Associated Infection health record vendor, and the medication involved (Levophed). y Medication or Other Substance 0 100,000 200,000 300,000 400,000 Event Severity n % y Other/Uncategorized Incident 3294 44.10% y Perinatal Near Miss 897 12.01% Key Points When Reviewing Event Data Tips for Safety Event Report Collection y Pressure Ulcer Unsafe Condition 842 11.27% CHPSO staff are frequently asked to provide rates of Consider following a standardized format. One that many Null 2437 32.62% y Surgery or Anesthesia different event types for benchmarking. However, unlike have found helpful is the “SBAR” format, which stands for many other measures of quality and safety, voluntarily situation, background, assessment, and recommendation. In 2019, “Medication or Other Substance” was the second- Age n % collected and submitted event reports cannot be utilized This communication model is useful for both internal review largest category in the CHPSO database, behind “Other/ Neonate (0 - 28 days) 27 <1% in this fashion. and patient safety organization review. Uncategorized.” As part of our continual efforts to improve Infant (>28 days <1 year) 47 <1% A number of concepts are helpful to understand when Remember the report needs to be complete but does our understanding of safety event reports submitted by our Child (1 - 12 years) 646 8.65% members, CHPSO has completed an analysis of a subset of reviewing safety event reports and other data types not need to be lengthy. Whenever possible, spell out Adolescent (13 - 17 years) 41 <1% these medication-related events. collected by patient safety organizations. One is that the abbreviations and acronyms. For instance, PT might be Adult (18 - 64 years) 1279 17.12% volume of reports does not equal prevalence. used for both physical therapy and patient. For this report, we analyzed a subset of the safety event Mature Adult (65 - 74 438 5.86% It is easy to assume that a higher number of a certain type Stick to the facts and avoid blaming or shaming. In a culture reports in the “Medication or Other Substance” category years) of event means there are more of those types of events of safety, event reports are not meant to point out who is submitted to CHPSO in 2019. For inclusion in this analysis, Older Adult (75 - 84 years) 359 4.81% events had to meet the following criteria: a maximum of 50 occurring. However, given the nature of safety event reporting, right and who is wrong. Aged Adult (85+ years) 202 2.70% it simply means hospitals have submitted more of those random events per facility where DE21 = “A54” and event Indicate whether the event happened for the first time or if Null 4431 59.32% types of events to the CHPSO database. load date occurred in 2019. These data included 7,470 it has occurred multiple times — this helps CHPSO pick up safety event reports from 186 individual CHPSO member Harm n % It is also important to understand that CHPSO does not on themes related to event frequency. It is also helpful to facilities. This is an overview of frequently mentioned drug Death 4 <1% require members to change the way they collect event include relevant follow-up in the report. categories and areas identified as opportunities for improve- reports for their own patient safety, quality, and risk ment, as well as a discussion of clinically relevant topics Severe harm 13 <1% Encourage the submission of reports of near-misses and management purposes. In addition, CHPSO does require associated with these events. Moderate harm 181 2.42% no-harm events. Staff often do not report no-harm and members to submit information in specific fields. As a result, near-miss events. These incidents, however, represent “free Mild harm 1197 16.02% we receive information in various degrees of thoroughness As with previous analyses of safety events, many events in lessons” and may turn out to be precursors of serious events. No harm 2081 27.86% and quality. this dataset were multifactorial. Therefore, the total number of events in each category is greater than the total number Null 3994 53.47% DATA QUALITY Frequently mentioned drug categories included Opioids Medication dispensing and administration errors were also Percentage of Fields Null vs. Not Null — CHPSO 2012 to 2019 (n=1363), Antimicrobials (n=1082), Anticoagulants (n=848), commonly found in this dataset (n=1387). These included % Null % Not Null % All Listed Fields Not Null * ** Acetaminophen (n=678), and Benzodiazepines (n=481). errors related to wrong drug, wrong frequency/time, wrong 100% Opioids and benzodiazepines were frequently associated patient, and wrong dose. with safety event reports related to controlled substance CPOE- and EHR-related issues often overlapped during accountability and management of the inventory in dispensing these events (e.g., weight-based dosing errors). Also cabinets. At first glance, acetaminophen appeared to have overlapping with this category were issues related to 52.9% been an issue in many of the events in the dataset, by virtue 50% 45% the management of IV lines (n=352) and infusion pumps of the number of times it was mentioned. However, upon (n=142). While not the largest categories in the dataset, we further investigation, we found acetaminophen was most found these issues worth mentioning due to the high risk for frequently mentioned because it is an ingredient in opioids. 15% 17% patient harm. Examples in these subcategories include: 12% 5% In fact, when we counted only events in which acetaminophen 0% 1% 4% was specifically mentioned in the event descriptions (free- 0% y Guardrails and medication libraries were not used Event Event Date Event Event Event Age** Gender** Extent of text fields) — based on key words such as acetaminophen, Number Type Occurred Severity Description Harm** or were unavailable Ofirmev, and Tylenol — we found a significant decrease * Only reports with no missing values on all the ** Age/Gender/Extent of Harm field is calculated only CHPSO database analysis of the number of fields listed above are included for calculation. for incident event reports. Refer to Age/Gender section events with null fields in specified categories (n=172) in the number of events. y Availability of infusion pumps and/or infusion below for more information. pumps malfunctioning Events related to antimicrobials included a variety of sub- categories and factors. These included missed or delayed y Incorrectly programed infusions (e.g., wrong drug/ Assessing Event Reporting Data Quality CHPSO recommends submitting all event fields collected doses due to medication availability, omissions or delays due rate/concentration) within the member’s event reporting system.