ursula harrisson - victorian management & insurance authority - risk insights and patient safety...
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Risk insights and patient safety issues in emergency medicine21 July 2016
Ursula Harrisson, Risk Advisor Medical Indemnity
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Our work at VMIA
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Our products and services
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Patient safety focus areas
Culture
Governance
Transparency Safer practice
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What is the problem?
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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
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Causes of death (USA)
All causes2,597K
Cancer585K
Heart
disease611K
COPD149K
Suicide
41K
Firearms
34K
Motor
vehicles
34K
Medical
error251K
Source: BMJ Publishing Group
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Source: Daily Telegraph
Industry and inquest experience
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What do claims tell us
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What do claims tell us?
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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
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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
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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
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What is the solution
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What is the solution?
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Improving patient safety
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Education and training
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Communication
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• Greater availability of ED consultants
• Review of high Risk Patients
• Improve Access to pharmacists and radiologist
• Electronic prescribing
System interventions
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Guidelines and protocols
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Culture and patient engagement
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Engage your executive and board
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What is the future
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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
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Thank you