1. Systems for Safety June 2006

2. Much has Been Done … Trend in Age-Adjusted 30-Day In-Hospital Death Rate Excludes NL, QC, BC

3. But Challenges Remain of Canadian adults report that they, or a family member, experienced a preventable “adverse event”

4. How often do adverse events happen? Hospital-acquired infection (kids) Birth traumaAdults with health problems given wrong medication/dose

5. Foreign object left inInfected transfusion blood: HIV In-hospital hip fractures for seniors How often do adverse events happen?

6. Information for Improvement…

7. Data Systems for Safety: Addressing Many Challenges How do we identify for follow-up:  Patients at risk of adverse events  Patients who may have experienced an adverse event How do we know the extent of the problem and how it is changing? How do we know which changes to try? How do we know that change is an improvement? How can we demonstrate accountability? How do we learn and spread lessons from adverse events or near misses? Etc.

8. Tracking Progress: Vital Signs Team by Team Project by Project Big Dot - Overall mortality trends -Trends in care processes - Intervention-level outcomes -Tracking team’s care processes

9. Medication Incidents: Example #1 Information on number, types, sources, causes and outcomes… Is needed to  Identify areas requiring change  Identify potential preventative strategies  Assist in implementing strategies that have been shown to reduce the risk of incidents  Evaluate implementation outcomes

10. Different approaches for different needs … Chart reviews Patient Safety SurveysIndicators Reporting Systems EHR & Decision-support

11. Primary Health Care Indicators: Example #2 Type of Data Source Required Current Data Source s Modifie d Data Source s Expand ed Data Source s No Current Data Source Total Client/patient or population surveys 9 5 17 -31 Provider survey data6 4 5 15 Organization survey data --21 223 Clinical administrative data 1 3 12 1733 Other administrative data 2 --13 TOTAL18125520105

12. Information for Improvement What is the Potential?

14. At the Practice Level CHF Collaborative in BC PrePost % on ACE-I/ARB24%93% % on beta blockers21%89% % self-management goals4%57% Source: http://www.heartbc.ca/pro/collaboratives/chf/docs/chf-finalposter.pdf

15. The Pharmanet Story Out of 35 million prescriptions in 2003  7.9 million potential interactions flagged  12% “most significant” –Generally require action to reduce risk of serious adverse event Most common reasons for not dispensing as written in 2003  Consulted provider, changed dose/instruction  Sub-therapeutic dose  Prior adverse reaction

16. Adverse Event Reporting

17. Informing Management Decisions Within a year, 92% of Ontario hospitals had taken action based on data reported in the Hospital Reports Common areas for action included improving communication and coordination of care

18. 30-Day In-Hospital Death Rate Following New Heart Attack Admission Lowest7.6% Overall11.1% Highest16.3% Regional Differences 2002–2003 to 2004–2005, excluding QC & NL

19. The Road Ahead …