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Hot Topics In Patient SafetySally Sims, PharmD
Speaker Disclosure
I have no affiliations or significant financial interests with manufacturers of any commercial product and/or providers of commercial services, and am not supported by grants/research support or status as an employee, consultant, major stockholder, or member of a speakers bureau.
Objectives• Outline and understand perspective of regulatory agencies regarding Patient Safety
• Review and acknowledge current methodologies for measuring Patient Safety
• Discuss strategies for prioritizing pharmacy resources in Patient Safety Initiatives
• Examine the Falls Reduction initiative in Patient Safety, highlight the role of medications in Falls, and consider strategies for pharmacy staff interventions
• Explore methods for collecting and quantifying Adverse Drug Events [ADE’s]
• Comprehend current state of nationally targeted ADE management
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Objectives -> Hot Topics• Patient Safety: What is it and how do I know if we have it or not?
• Falls
• Adverse Drug Events [ADE’s]
• Prioritizing Pharmacy Resources
ACPE Definition: Patient Safety
The prevention of healthcare errors, and the elimination or
mitigation of patient injury caused by Healthcare Errors [An
unintended healthcare outcome caused by a defect in the
delivery of care to a patient]
Healthcare errors may be errors of:
• Commission (doing the wrong thing)
• Omission (not doing the right thing)
• Execution (doing the right thing incorrectly)
Errors may be made by any member of the healthcare team in any healthcare setting.
ACPE Policies and Procedures Manual: A Guide for ACPE Accredited Providers. (2017). Retrieved from https://www.acpe‐accredit.org/pdf/CPE_Policies_Procedures.pdf p35.
Active LearningMatch the Type of Error With Its Meaning
Commission
Doing The Wrong Thing
Omission
Not Doing the Right Thing
Execution
Doing The Right Thing Incorrectly
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Patient Safety Organizations• Agency for Healthcare Research & Quality [AHRQ]
https://www.ahrq.gov/
• Institute for Healthcare Improvement [IHI] http://www.ihi.org
• Pennsylvania Patient Safety Authority
http://patientsafety.pa.gov/
Regulatory & Accreditation Organizations
• Centers for Medicare & Medicaid Services [CMS] https://www.cms.gov
• The Joint Commission [TJC] https://www.jointcommission.org
• Centers for Disease Control & Prevention [CDC] https://www.cdc.gov
Regulatory Agencies Perspectives
• CMS adopted Patient Safety Indicators developed by AHRQ
• Affordable Care Act [ACA]
➢ Established Hospital‐Acquired Condition [HAC] Reduction Program
• Requires Secretary of Department of Health and Human Services [HHS] to adjust payments
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Regulatory Agencies Perspectives
• AHRQ Patient Safety Indicators | PSI 90 Composite Score
➢ Pressure Ulcers*
➢ Iatrogenic Pneumothorax
➢ Fall with Hip Fracture*
➢ Peri‐operative:
• Hemorrhage/Hematoma
• Pulmonary Embolism/Deep Vein Thrombosis
• Unrecognized Abdominopelvic Accidental Puncture/Laceration
➢ Post‐operative:
• Acute Kidney Injury Requiring Dialysis
• Sepsis
• Wound Dehiscence
*CMS Nursing Home Quality Measures
https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/Downloads/FY2018‐HAC‐Reduction‐Program‐Fact‐Sheet.pdf
Regulatory Agencies Perspectives
• Hospital‐Acquired Condition Reduction Program 2018
➢ PSI 90 Composite Score
➢ Central Line‐Associated Bloodstream Infection [CLABSI]
➢ Catheter‐Associated Urinary Tract Infection [CAUTI]*
➢ Surgical Site Infection [SSI]
➢ Methicillin‐resistant Staphylococcus aureus [MRSA] bacteriemia
➢ Clostridium difficile Infection [C‐Diff]
*CMS Nursing Home Quality Measures
https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/Downloads/FY2018‐HAC‐Reduction‐Program‐Fact‐Sheet.pdf
Regulatory Agencies Perspectives
CMS Star Ratings
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Active LearningWhich of the following is NOT a Healthcare
Acquired Patient Safety Indicator?
A. Pressure Ulcer
B. Urinary Tract Infection
C. Fall
D. Diabetes
Measuring Patient Safety
• By the Numbers:
• Patient Safety Indicators
• Adverse Drug Events
• By the Culture
• AHRQ Culture of Safety Survey
Measuring Patient SafetyAHRQ Safety Culture Surveyshttps://www.ahrq.gov/sops/index.html
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Measuring Patient Safety
Use AHRQ Safety Culture Surveys To:
• Raise staff awareness about patient safety
• Diagnose and assess the current status of patient safety culture
• Identify strengths and areas for patient safety culture
• Examine trends in patient safety culture change over time
• Evaluate the cultural impact of patient safety initiatives and interventions
• Conduct internal and external comparisons
https://www.ahrq.gov/sops/index.html
Measuring Patient SafetyAHRQ Culture of Safety Surveys
Measure Perceptions of:
• Teamwork
• Communication
• Leadership Support
• Staffing
• Error Reporting
Active LearningAHRQ provides Culture of Safety Surveys for which of the following practice settings?
A. Hospital
B. Nursing Home
C. Community Pharmacy
D. All of the above
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Hot Topic: FALLS
Falls are NOT an inevitable part of aging.
There are specific things that you, as their health care
provider, can do to reduce their chances of falling
https://www.cdc.gov/steadi/index.html
Facts About Falls• A patient fall is defined as an unplanned descent to the floor with or without injury to the patient
• Between 700,000 and 1,000,000 people in the United States fall in the hospital annually➢1 in 4 older adults in community setting➢40‐50% Nursing Home Residents➢Top 1st or 2nd Type Sentinel Event in Hospitalized Patients
• A fall may result in fractures, lacerations, or internal bleeding, leading to increased health care utilization or death
• As of 2008, the Centers for Medicare & Medicaid Services (CMS) does not reimburse for fall related injuries
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
Facts About Falls
https://www.cdc.gov/steadi/index.html
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Facts About Falls
Falls are the leading cause of both fatal and non-fatal injuries among people aged 65 years and older
https://www.cdc.gov/steadi/index.html
Falls Reduction Toolkit:Institutional Settings
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
Falls Reduction Toolkit:Community/Ambulatory Settings
https://www.cdc.gov/steadi/index.html
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Falls Reduction Toolkit:Community/Ambulatory Settings
CDC STEADI: Materials for Healthcare Providers
https://www.cdc.gov/steadi/index.html
Core Falls Prevention Activities
Screen: Risk Factors
• Age-related decline➢ Changes in visual function➢ Proprioceptive system, vestibular system
• Chronic disease ➢ Parkinson’s disease➢ Osteoarthritis➢ Cognitive impairment➢ Diabetes➢ Cardiovascular disease
• Acute illness
• Medication use
American Geriatrics Society www.americangeriatrics.org|www.geriatricscareonline.org|Falls Prevention
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Screen: Risk AssessmentInstitutional Example
Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3h.html
Morse Fall Scale
Screen: Risk AssessmentCommunity Example
https://www.cdc.gov/steadi/index.html
Screen: Risk Factors
• Specific classes, for example:➢Benzodiazepines➢Other sedatives➢Antidepressants➢Antipsychotic drugs➢Cardiac medications➢Hypoglycemic agents
• Recent medication dosage adjustments
• Total number of medications
American Geriatrics Society www.americangeriatrics.org|www.geriatricscareonline.org|Falls Prevention
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Screen:Medication Risk Assessment
Tool 3I: Medication Fall Risk Score and Evaluation Tools. Content last reviewed January 2013. Agency for Healthcare Reseand Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3i.html
Screen:Medication Risk Assessment
Tool 3I: Medication Fall Risk Score and Evaluation Tools. Content last reviewed January 2013. Agency for Healthcare Reseand Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3i.html
Assess:Identify Modifiable Risk Factors
•Treatment goals•Current medication regimen
Include OTC, supplements, allergies, alcohol use, and recreational drug use•Side effects experienced•Non‐pharmacologic options•Patient values and preferences [Handout]•Barriers to care
Low health literacy, physical and cognitive impairment, socioeconomic barriers ‐> medication adherence
https://www.cdc.gov/steadi/index.html
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Intervene:Use Clinical & Community Strategies
Use Multifactorial Interventions Including:➢ Minimize medications
• Stop when possible• Switch to safer alternatives• Reduce to lowest effective dose
➢ Develop a monitoring plan for medication side effects
➢ Supplement Vitamin D➢ Manage postural hypotension, and
heart rate and rhythm abnormalities
American Geriatrics Society www.americangeriatrics.org|www.geriatricscareonline.org|Falls Prevention
Intervene:Use Clinical & Community Strategies
Use Multifactorial Interventions Including:➢ Explore non-pharmacologic options to
manage medical conditions• Initiate individually tailored exercise
program• Treat vision impairment
➢ Manage foot and footwear problems➢ Modify the home environment
American Geriatrics Society www.americangeriatrics.org|www.geriatricscareonline.org|Falls Prevention
THINK - PAIR - SHARE
Pair up in groups and discuss:
1. What toolkit resource is most applicable for my practice setting?
2. What is the current status of a falls prevention initiative in my practice setting?
3. What one thing can I do when I go back to work to advance falls prevention activities in my practice setting?
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THINK - PAIR - SHARE
Potential Discussion Answers:
• Institutional ‐ AHRQ
• Community/Ambulatory ‐ CDC STEADI
• Not started | Early Stages | Advanced
• ID workflow options to incorporate | Talk to my supervisor | Develop/Adopt a risk assessment tool
Hot Topic: ADE’s"Our figures show approximately four
and one half million hospital admissions annually due to the adverse reactions to
drugs. Further, the average hospital patient has as much as thirty percent
chance, depending how long he is in, of doubling his stay due to adverse drug
reactions." Milton Silverman, M.D. (Professor of
Pharmacology, University of California)
Collecting & Quantifying ADE’SIn order to solve a problem you must first define it
and accurately quantify it
• Adverse Drug Event (ADE): an injury to a patient resulting from a medication intervention, which can occur in any health care setting
• Reporting: ➢ Systems, Data, & Culture
• Systems: Paper, Database, E‐mail?
• Data: Where does info go and who manages it?
• Culture: Punitive, Blame Free, Just Culture?
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Collecting & Quantifying ADE’S:Quantify and Prioritize Collected Data
http://www.nccmerp.org/sites/default/files/indexColor2001‐06‐12.pdf
Collecting & Quantifying ADE’S
Prioritize➢ Severity: Signal or Sentinel Event
➢ High Risk• High Alert Medications
• Look‐A‐Like Sound‐A‐Like
• Hazardous Medications
• Regulatory
➢ Trends
➢ Targeted Initiatives
• [Opioids, Anticoagulants,Hypoglycemia]
CMS Targeted ADE Management:
The Centers for Medicare & Medicaid Services awarded the Health Research & Educational Trust (HRET) a two‐year HIIN Hospital Improvement Innovation Network (HIIN)contract (with an optional third year based on performance), to continue efforts to reduce all‐cause inpatient harm by 20 percent and readmissions by 12 percent by 2018
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-09-29-2.html
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CMS Targeted ADE Management:
Health Research & Educational Trust (February 2017). Adverse Drug Events Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org
• The Office of Disease Prevention and Health Promotion (ODPHP) released The National Action Plan for ADE Prevention (ADE Action Plan) in October 2014.
• The report focused efforts on the group of ADEs that are common, clinically significant, preventable and measurable.
CMS Targeted ADE Management:
Health Research & Educational Trust (February 2017). Adverse Drug Events Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret‐hiin.org
» ADE Targets• Anticoagulants ‐
Bleeding
• Diabetic Agents ‐Hypoglycemia
• Opioids ‐ Overdose, Over Sedation, Respiratory Depression, Death
Prioritizing Pharmacy ResourcesGroup Discussion
Within scope of pharmacy practice
Accreditation Standard
CMS Priority
Severity of Harm
Frequency of Events
Cost of Intervention
Impact on Workflow
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