1. Overview of AHRQ Resources to Improve Patient Safety September 15, 2009

2. Overview & Introduction Overview & Introduction – Jeff Brady, M.D., AHRQ, CQuIPS Speakers 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 Agenda

3. To Err is Human: Building a Safer Health System 44,000 – 98,000 deaths/yr 44,000 – 98,000 deaths/yr 8 th leading cause of death in US 8 th leading cause of death in US National Costs: $17 to $29 billion National Costs: $17 to $29 billion $2 billion Adverse Rx event costs alone $2 billion Adverse Rx event costs alone – 2% hospital admissions (preventable) – Add $4,700 in costs to each hospitalization Institute of Medicine, 1999

4. 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)

5. AHRQ’s Mission Improve the quality, safety, efficiency and effectiveness of health care for all Americans

6. 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

7. AHRQ Core Business Areas Creation of Knowledge Creation of Knowledge Synthesis and Dissemination Synthesis and Dissemination Implementation and Use Implementation and Use

8. AHRQ Patient Safety Budget * Projected 0 10 20 30 40 50 60 Millions 200020022004200620082010 Fiscal Year

9. 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

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

11. AHRQ Patient Safety Resources Transforming Hospitals: Designing for Safety and Quality Transforming Hospitals: Designing for Safety and Quality Advances in Patient Safety: From Research to Implementation Advances in Patient Safety: From Research to Implementation Advances in Patient Safety: New Directions and Alternative Approaches Advances in Patient Safety: New Directions and Alternative Approaches Patient Safety and Quality: An Evidence-Based Handbook for Nurses Patient Safety and Quality: An Evidence-Based Handbook for Nurses Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety 10 Patient Safety Tips for Hospitals 10 Patient Safety Tips for Hospitals Guide for Developing Patient Safety Councils Guide for Developing Patient Safety Councils Your Guide to Preventing and Treating Blood Clots Your Guide to Preventing and Treating Blood Clots Blood Thinner Pills: Your Guide to Using Them Safely Blood Thinner Pills: Your Guide to Using Them Safely http://www.ahrq.gov/qual/errorsix.htm

12. A world of patient safety information at your fingertips AHRQ Patient Safety Network (PSNet) and WebM&M

13. 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.govhttp://psnet.ahrq.gov psnet.ahrq.gov

15. Search

16. Patient Safety Primers

17. 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.govhttp://webmm.ahrq.gov webmm.ahrq.gov

19. Evidence-based Team Training and Implementation Toolkit Set of ready-to-use materials and training curricula to integrate teamwork principles 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 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 Collaboration between AHRQ and Department of Defense’s military health system http://teamstepps.ahrq.govhttp://teamstepps.ahrq.gov/ http://teamstepps.ahrq.gov

20. 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 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 Discusses how communication and teamwork strategies taught via TeamSTEPPS tools can work for Rapid Response Systems CD includes: CD includes: – PowerPoint presentations – Teaching modules – Video vignettes AHRQ Publication No. 08(09)-0074-CD.

21. AHRQ Suite of Patient Safety Culture Survey Tools Suite of tools that measure patient safety culture in Suite of tools that measure patient safety culture in – Hospitals – Medical offices – Nursing homes Tools include survey instruments and report templates Tools include survey instruments and report templates User's Guide provides information on 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

22. Hospital Survey on Patient Safety Culture Helps hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units Helps hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units Includes survey guide, survey, and feedback report template to customize reports Includes survey guide, survey, and feedback report template to customize reports AHRQ partnership with Premier, Inc., Department of Defense, and American Hospital Association AHRQ partnership with Premier, Inc., Department of Defense, and American Hospital Association http://www.ahrq.gov/qual/hospcul ture/ or e-mail to ahrqpubs@ahrq.gov http://www.ahrq.gov/qual/hospcul ture/ or e-mail to ahrqpubs@ahrq.gov http://www.ahrq.gov/qual/hospcul ture/ http://www.ahrq.gov/qual/hospcul ture/

23. Hospital Culture Survey Comparative Database Provides results hospitals can use as benchmarks in establishing a patient safety culture. 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. 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. Appendixes provide data tables and show trends over time.

24. Nursing Home Survey on Patient Safety Culture Pilot tested in 40 nursing homes Pilot tested in 40 nursing homes Survey materials and technical assistance for survey administration are free Survey materials and technical assistance for survey administration are free Use the survey to: 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

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

26. Guide Available for Deep Vein Thrombosis Developed from Partnerships in Implementing Patient Safety program toolkit 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 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) Assists quality improvement practitioners in preventing one of the most important problems facing hospitalized patients - DVT / PE (VTE) http://www.ahrq.gov/qual/vtguide/

27. Why build a toolkit for VTE Prevention? VTE is a common source of inpatient M&M 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 Effective and safe methods of prevention exist – Large “implementation gap” - best practice ≠ current practice These methods are grossly underutilized These methods are grossly underutilized – Awareness, difficulty implementing, no validated risk assessment P4P, public reporting, and core measures P4P, public reporting, and core measures 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

28. To Achieve Improvement Real institutional support / prioritization Real institutional support / prioritization Will to standardize Will to standardize Physician leadership Physician leadership Measurement of process / outcomes Measurement of process / outcomes Protocol, integrated into order sets Protocol, integrated into order sets Education Education Continued refinement / tweaking- PDSA Continued refinement / tweaking- PDSA SHM and AHRQ Guides on VTE Prevention

29. Hierarchy of Reliability No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) (by other QI / high reliability strategies) Oversights identified and addressed in real time Level 4 1 2 3 5 Predicted Prophylaxis rate 40% 50% 65-85% 90% 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

30. The Essential First Intervention The Essential First Intervention 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 30 VTE Protocol

31. Low Medium High Ambulatory with no other risk factors. Same day or minor surgery CHF 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 75 or weight <50 kg)LMWH Enox 40 mg q day Enox 40 mg q day Other LMWH 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 31 IPC needed if contraindication to AC exists Example from UCSD Keep it Simple – A “3 bucket” model

32. Map to Reach Level 3 Implementing an Effective VTE Prevention Protocol Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis. Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis. Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment) Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment) Vette / Pilot – PDSA Vette / Pilot – PDSA Educate / consensus building Educate / consensus building Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets. Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets. Monitor, tweak - PDSA Monitor, tweak - PDSA

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

34. 34 UCSD - Decrease in Patients with Preventable HA VTE 0 2 4 6 8 10 12 14 Q 1 '05 Q2 '05Q3 '05Q4 '05 Q1'06 Q2 '06Q3 '06Q4 '06Q1 '07 Quarter # of Patients Medicine Surgery Ortho Other Total

35. Hierarchy of Reliability No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) (by other QI / high reliability strategies) Oversights identified and addressed in real time Level 4 1 2 3 5 Predicted Prophylaxis rate 40% 50% 65-85% 90% 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

36. 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: 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!

37. Situational Awareness and Measure-vention: Getting to Level 5 Identify patients on no anticoagulation Identify patients on no anticoagulation Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications) 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 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” Need Administration to back up these interventions and make it clear that docs can not “shoot the messenger”

38. Collaborative Efforts and Kudos SHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative I - 25 sites SHM / VA Pilot Group - 6 sites SHM / VA Pilot Group - 6 sites SHM / Cerner Pilot Group – 6 sites SHM / Cerner Pilot Group – 6 sites AHRQ / QIO (NY, IL, IA) - 60 sites AHRQ / QIO (NY, IL, IA) - 60 sites IHI Expedition to Prevent VTE – 60 sites IHI Expedition to Prevent VTE – 60 sites SHM Team Improvement Award SHM Team Improvement Award NAPH Safety Net Award NAPH Safety Net Award Venous Disease Coalition Venous Disease Coalition

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

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

41. Evidence Based Design Build Private Rooms Build Private Rooms Reduce Noise Reduce Noise Incorporate Nature Incorporate Nature Improve Air Quality Improve Air Quality Encourage Hand Hygiene Encourage Hand Hygiene Improve Wayfinding Improve Wayfinding Reduce Walking Distance Reduce Walking Distance

42. Transforming Hospitals: Designing for Safety and Quality A DVD that demonstrates how evidence-based design can improve the quality and safety of hospital services while improving staff satisfaction and retention 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 Case studies of three hospitals illustrate the benefit of incorporating evidence-based design principles into new construction or renovation projects AHRQ Publication No. 07-0076-DVD

43. Advances in Patient Safety: From Research to Implementation Four-volume set of 140 peer-reviewed articles representing an overview of patient safety studies Four-volume set of 140 peer-reviewed articles representing an overview of patient safety studies AHRQ Publication No. 05-0021-CD

44. Describes new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools to prevent harming patients 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 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 Advances in Patient Safety: New Directions and Alternative Approaches AHRQ Publication No. 08-0034 (print copy) or 08-0034-CD (Searchable CD-ROM)

45. Handbook for Nurses Comprehensive, 1400-page handbook for nurses on patient safety and quality. 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 : 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)

46. Patient Safety Improvement Corps DVD features a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level. DVD features a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level. Modules address: 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

47. 10 Patient Safety Tips for Hospitals Evidence-based tips help hospitals promote patient safety Evidence-based tips help hospitals promote patient safety Go to: http://www.ahrq.gov/qual/10tips.pdf Go to: http://www.ahrq.gov/qual/10tips.pdfhttp://www.ahrq.gov/qual/10tips.pdf

48. Guide for Developing Patient Safety Councils Provides information and guidance to empower individuals and organizations to develop a community-based advisory council 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 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 Councils drive change for patient safety through education, collaboration, and consumer engagement http://www.ahrq.gov/qual/advisorycouncil/

49. 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 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: 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 Created by experts funded through AHRQ's Partnerships in Implementing Patient Safety grant program http://www.ahrq.gov/consumer/bloodclots.htm

50. Blood Thinner Pills: Your Guide to Using Them Safely Consumer publication and DVD explain what to expect and watch out for while taking blood thinner pills 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 Based on research originally conducted by one of AHRQ’s Partnership for Implementing Patient Safety grant projects Educates patients about: Educates patients about: – Medication therapy and potential side effects – How to communicate effectively with their health care providers – Tips for lifestyle modifications http://www.ahrq.gov/consumer/btpills.htm

51. 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 email to AHRQPubs@ahrq.hhs.gov