Unintended Consequences & Patient Safety

1. Unintended Consequences & Patient Safety Friday, March 1, 2013 Victoria Aceti Chlebus Lecture 12

2. Unintended Consequences • What is Patient Safety? • The Baker Study • Methodology • Results • Limitations • How Health Informatics can help • Final Thoughts Agenda Unintended Consequences & Patient Safety

3. Unpredictable complications, issues or challenges that arise from introducing a new technology. • Documented cases of unintended consequences: • http://www.oha.com/KnowledgeCentre/Library/CoronersReports/Documents/Negus%20Tefari%20Topey%20Inquest%20-%20Documentation,Health%20Records,Reporting.pdf Unintended Consequences Unintended Consequences & Patient Safety

4. Process of Entering & Retrieving Information Communication & Coordination Process Errors • Not suitable human-computer interface • Cognitive overload • Structure • Fragmentation • Overcompleteness • Misrepresenting work as linear • Inflexibility • Urgency • Workarounds • Transfers • Misrepresenting communication as information transfer • Loss of feedback • Decision support overload • Catching errors Unintended Consequences: Types Unintended Consequences & Patient Safety

5. Patient Safety Indicators of Patient Safety: Adverse events Rate of infection (C.Diff, MRSA, VRE) Mortality trends Prevention practices (hand hygiene) “The reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes” (CIHI, 2007). Unintended Consequences & Patient Safety

6. Patient Safety Reporting Unintended Consequences & Patient Safety

7. Patient Safety Reporting: How do we Stack up? Unintended Consequences & Patient Safety

8. Group of researchers headed by Baker • There was little evidence of how safe patients were in Canadian acute care centres • Baker and colleagues looked specifically at adverse events as an indicator of patient safety • Government of Canada funded Canada Patient Safety Institute $50million over 5 years • Aimed to identify the type and frequency with which adverse events occur in Canadian acute care facilities The Baker Study Unintended Consequences & Patient Safety

9. Harvard Medical School Methodology (1984) • 4 hospitals in 5 provinces (BC, AB, ON, PQ, NS) – randomly selected patient charts • 2 stage chart review process and 18 listed inclusion criteria • Reviewed by medical professionals The Baker Study: Methodology Unintended Consequences & Patient Safety

10. Adverse events tended to happen more frequently in teaching hospitals than small or community hospitals 7.5% of hospital admissions resulted in adverse events, 37% of which could have been preventable. The Baker Study: Results Unintended Consequences & Patient Safety

11. Adverse events occurred more frequently with surgical patients • Adverse events occurred more frequently with older patients • Most patients recovered from reaction within 6 months The Baker Study: Results Unintended Consequences & Patient Safety

12. Budget constraints limited scope of study • Looked only at adult populations • Excluded obstetrics and psychiatry • Human subjectivity of medical reviewers and not on a scale (length of stay & prevention) The Baker Study: Limitations Unintended Consequences & Patient Safety

13. How informatics can help Unintended Consequences & Patient Safety Baker: Suggested that electronic medical records would assist in future studies and in the development of quality improvement studies Legibility of medication orders Computerized order entry (reminders and alerts) Automated drug administration (bar codes & “smart” IVs)

14. How informatics can help? Unintended Consequences & Patient Safety • Beyond looking at the technologies, we have to look at solutions by: • Using data to look at what the largest communication challenges are • Looking at the issues instead of new technology • For example: most successful informatics in recent years, Surgical checklist.

15. Unintended Consequences & Patient Safety

16. Issues that arise from the integration of informatics can cause high risk adverse events • Knowledge of current statistics of adverse event rates in Canada is the first step in tackling the issue. • Health informatics can help, but must look at the issue and not the ‘sexy’ technology. Final Thoughts Unintended Consequences & Patient Safety