“Never Events”: Will They (N)Ever Go Away? Maryland Association for Healthcare Quality October 29, 2009 Health Science Institute Larry L. Smith Vice President,

Slides:

Advertisements

Similar presentations

Adverse Patient Safety Events: Costs of Readmissions and Patient Outcomes Following Discharge Didem M. Bernard, Ph.D. William E. Encinosa, Ph.D.

Advertisements

Safe Surgery Dr. Mohamed Selima. The problem: Complications of surgical care have become a major cause of death and disability worldwide. Data from 56.

An Imperative for Performance Improvement

Healthcare Safety: How will your next patient be injured?

PATIENT SAFETY Justin MFIZI Patient Safety officer KFH.

Seeing safety through the patient’s eyes The trajectory of harm Charles Vincent Department of Experimental Psychology, Nuffield Department of Surgical.

1 of 33 Incident Reporting 2009 employee education competency module DMC Corporate Quality Department Detroit Medical Center© Revised: December, 2008.

Medical Errors Frances Symons PHE 570. Definition- Medical Error Failure of a planned action to be completed as intended or the use of a wrong plan to.

Canadian Disclosure Guidelines. Disclosure - Background Process began: May 2006 Background research and document prepared First working draft created.

Surgical safety is a serious public health issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications.

Dr. ABDULLAH ABDU ALMIKHLAFY Assistant professor & Head of community medicine department Presented By University of Science & Technology Sana’a – Yemen.

Collaborative to Reduce Healthcare Associated Infections

Capturing and Reporting Adverse Events in Clinical Research

Medication Reconciliation in Continuing Care Getting It Right Together Creating a Culture of Safety September 8, 2008 Dr. Paula Creighton MD, FRCP(C) Geriatric.

The Nature of Errors Richard M. Satava, MD FACS Professor of Surgery University of Washington School of Medicine and Program Manager, Advanced Biomedical.

DIVISION OF HEALTH CARE FINANCING & POLICY Patient Protection and Affordable Care Act Provider-Preventable Conditions.

+ Global Challenges in Patient Safety Reshma Ramachandran November 17, 2020.

Healthcare Errors Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. By IOM.

Human Factors & Patient Safety

Safety Basic Science December 22 nd, Safety Attitudes Questionnaire (SAQ) I am encouraged by my colleagues to report any patient safety concerns.

Using Root Cause Analysis to Make the Patient Care System Safe John Robert Dew The University of Alabama.

Overview of Never Events and Hospital Acquired Conditions in Medicare and Medicaid Barbara Dailey, Director Division of Quality, Evaluation, and Health.

IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Worksite Safety Indicators Total Recordable Injury Incident Rate Never Occurring 100%?

Risk Management in the New Era of Healthcare Reform February 26, 2011 James W. Saxton, Esquire Chair, Healthcare Litigation and Risk Management Group Stevens.

Incident Report By miss.EMAN Objectives At the end of this lecture student will be able : Define incident report List elements of incident report Discuss.

NORTH AMERICAN SAFETY CHECKLIST – SB 158. Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc. Presented By:

Component 1: Introduction to Health Care and Public Health in the US Unit 6- Regulating Health Care Lecture a- Regulatory Agencies— JCAHO, FDA, AMA, &

Safety: It’s Everybody’s Business Virginia Ingram, MSN, RN Patient Safety Officer University of Mississippi Medical Center.

Conducting an Infection Associated Root Cause Analysis John R. Rosing, MHA, FACHE Vice President and Principal Patton Healthcare Consulting May 3, 2012.

Supporting Quality Care

Topic 10 Patient safety and invasive procedures. Learning objective The objective of this topic is to understand the main causes of adverse events in.

Responsibilities and Principles of Drug Administration

Learning From Patient Safety Events in Acute Care Hospitals in Ontario Interactive Dissemination Workshop, November 10 th, 2009 g Sheraton Toronto Airport.

National Patient Safety Goals 2011

Occurrence Reports. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs.

The Role of Thromboprophylaxis in Elective Spinal Surgery The Role of Thromboprophylaxis in Elective Spinal Surgery VA Elwell, N Koo Ng, D Horner & D Peterson.

“Use data to shed light, not heat.” Source: Reinertsen JL et al 2007.

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10Safety Concerns in Healthcare.

The Disruptive Physician Federation of State Physician Health Programs 2010 Annual Meeting Doris C. Gundersen, MD Medical Director Colorado Physician Health.

Copyright © 2006 Elsevier, Inc. All rights reserved Chapter 22 Quality Patient Care.

ADMINISTRATION SERIES: MEDICAL ERROR Jay Green Dr. Lisa Campfens March 11, 2010.

Topic 10 Patient safety and invasive procedures. LEARNING OBJECTIVE The objective of this topic is to understand the main causes of adverse events in.

Managing Hospital Safety: Common Safety Concerns Part 1 of 4.

Disclosure of Medical Errors AND Risk Management

Occurrence Reports. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs.

Disclosing Medical Errors: 2008 and Beyond Wendy Levinson, MD Professor of Medicine University of Toronto.

Surgical safety is a serious public health issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications.

A Consumer’s Perspective on Medical Errors Kenneth L. Connor August 22, 2006.

Surgical safety is a serious public health issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications.

1 National Quality Forum Patient Safety Initiatives Melinda L. Murphy, RN, MS, CNA.

Aidah Abu Elsoud Alkaissi BSc law, RN, RNT, BSN, MSN, CCRN, CRNA, PhD Head of Nursing & Midwifery Department Faculty of Medicine & Health Sciences An-Najah.

Check a Box. Save a Life. The 1 st Global Student Sprint to Improve Healthcare October 22, 2009.

Chapter 4 Emergency Preparedness and Assessment. The Importance of Observational Skills During an Emergency Look Listen Touch Smell 2.

1 Parliamentary and Scientific Committee: meeting on patient safety Jocelyn Cornwell The Point of Care Foundation October 13 th 2015.

Clinical risk management Open Disclosure. Controlling Unpredictability of health Laws Civil law Parliamentary law & statues Client rights Professional.

The Department of Quality and Risk Management

Governing Body QAPI 2013 Update for ASC

Managing Hospital Safety: Common Safety Concerns

Disclosing and Resolving Adverse Outcomes

Medication Reconciliation in Continuing Care

Surgical safety is a serious public health issue

Surgical safety is a serious public health issue

Disclosure training Adverse patient events

Event & Disclosure Reporting

Why should we disclose? Patients have the Right to Know

Management and Communication

Rita Simmons Sr. Director, Operations Risk Management.

Adverse Event Analysis

Presentation transcript:

“Never Events”: Will They (N)Ever Go Away? Maryland Association for Healthcare Quality October 29, 2009 Health Science Institute Larry L. Smith Vice President, Risk Management, MedStar Health, Inc. President, MD-DC Society for Healthcare Risk Management

MHA’s Payment Guidelines on Serious Adverse Events Maryland Hospitals agreed that whenever one of these events result in death or serious disability to a patient the hospital would waive payment for any of the stay: –Surgery on wrong body part –Surgery on wrong patient –Wrong surgical procedure –Unintended retention of a foreign object –An air embolism that occurs while being treated –A medication error resulting in death, paralysis, coma or other major permanent loss of function. –A hemolytic transfusion reaction due to administration of incompatible blood or blood products

MHA’s Payment Guidelines on Serious Adverse Events In addition, Maryland Hospitals agreed to evaluate on a case-by-case basis whether full or partial payment should be waived for other event that resulted in patient death or serious disability based on: Was the error or event preventable? Was the error or event within the control of the hospital? Was the injury to the patient the result of a mistake made in the hospital?

MedStar’s Adverse Event Reporting System What is reported Serious Safety Harm Report –Any event resulting in death or serious harm –Surgery on wrong body part –Surgery on wrong patient –Wrong surgical procedure –Unintended retention of a foreign object –An air embolism that occurs while being treated –A medication error resulting in death, paralysis, coma or other major permanent loss of function. –A hemolytic transfusion reaction due to administration of incompatible blood or blood products

Source: Duke University Medical Center Patient Safety – Quality Improvement

Preventable Errors I Have Known Wrong: Limb Side of head (neurosurgery) Level spine surgery Patient (cath’ed) Procedure-right patient (bunioinectomy v. foot release) Blood Type Patient Circumcised Test results given to patient (AIDS) Solution used to clean site (100% acetic acid) Drug: – dose –Administration-route Organ(s) transplanted Organ removed Retained: Sponge Kelly Clamp Needle Retractor (14” by 3”) Tip of glove

How should we respond when a patient is injured due to error? Disclosure – What? When? Why? Who? Apology or Expression of Regret? To Bill or not to Bill? Discipline or Blamelessness?

Disclosure Why? –Right thing to do –Reinforces for staff that transparency is a core value of the organization and its leadership –Risk management issues are secondary, not primary……... “the patient may not sue” What? –The facts as we know them to be When? –As soon as the patient/family is psychologically and physically ready

Disclosure Who: –Requires a situational analysis – often best done by – or at least in the presence of - someone with a pre-existing relationship with the patient/family

Apology or Expression of Regret? Expressions of regret are appropriate for all unanticipated outcomes Apology is appropriate when the unanticipated outcome was clearly caused by unambiguous error or system failure