ursula harrisson - victorian management & insurance authority - risk insights and patient safety...

Risk insights and patient safety issues in emergency medicine21 July 2016

Ursula Harrisson, Risk Advisor Medical Indemnity

Our work at VMIA

Our products and services

4

Patient safety focus areas

Culture

Governance

Transparency Safer practice

6

What is the problem?

What is the extent of the harm to patients?

• Australian Data (1995)

– 16.6% - experience an adverse event

– 51% - preventable

• European Data (2000/ 2005)

– 8% -12% - with the average – 10% Hospital admissions

– 50 – 70.2% are preventable

– If they could prevent…….

• 750,000 episodes of harm is inflicted due medical error per year

– Lead to…………..

• >3.2 million fewer days of hospitalization

• 260,000 preventable permanent disability

• 95,000 fewer deaths

Causes of death (USA)

All causes2,597K

Cancer585K

Heart

disease611K

COPD149K

Suicide

41K

Firearms

34K

Motor

vehicles

34K

Medical

error251K

Source: BMJ Publishing Group

Source: Daily Telegraph

Industry and inquest experience

What do claims tell us

10

What do claims tell us?

Claims Data

296.0

85.1

38.0 35.9 32.925.3 24.0 19.9 15.8 14.2 13.9 13.2

83.9

0

50

100

150

200

250

300

350

0

100

200

300

400

500

600

700

800

900

Incu

rre

d c

ost

($

M)

Cla

im n

um

be

rs

Clinical specialty

VMIA Medical Indemnity claims experience - last 10 closed years 1 July 2005 to 30 June 2015

Incurred Cost ($M) Claim numbers11

VMIA claims data from 2003-2013 (Emergency medicine Speciality)

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

0

10

20

30

40

50

60

AAA Neurological Fracture Meningitis ACS Sepsis

To

tal C

ost o

f Cla

ims

No

. o

f C

laim

s

Condition

Top 6 Conditions over last 10 years

No.of Claims Total Cost of Claims

What are the Causal Factors?

Causal factor % of Claims

Diagnostic Error 55

Lack of appropriate supervision 30

Inadequate handover 24

Failure to adhere to clinical practice or hospital guidelines 17

Missed test results 16

Treatment delays 11

Medication error 6

What is the solution

14

What is the solution?

Improving patient safety

Education and training

Communication

• Greater availability of ED consultants

• Review of high Risk Patients

• Improve Access to pharmacists and radiologist

• Electronic prescribing

System interventions

Guidelines and protocols

Culture and patient engagement

Engage your executive and board

What is the future

VMIA Resources and Publications

• Roundtables and Risk Insight publications on Patient Safety:

• https://www.vmia.vic.gov.au/learn/risk-insights#Safer

– Emergency Medicine Roundtable examines causes of medical indemnity

claims

– Junior doctors contribution to patient safety and quality improvement

– Missed test results – improving the diagnosis process

– Safer Diagnosis: improving the diagnostic process to reduce risks to

patients

– The deteriorating patient

• ISBAR - https://www.vmia.vic.gov.au/risk/risk-tools/isbar

• Clinical Risks information -

https://www.vmia.vic.gov.au/learn/clinical-risk

• Managing Risk - https://www.vmia.vic.gov.au/learn/managing-risk

Thank you