How to measure harm

Amongst the many challenges we face in trying to improve safety of care is the paucity of knowledge we possess about the rate and types of harm occurring to our patients. The traditional approach has been to identify sentinel cases, either because they are obvious or they are reported via traditional risk reporting structures. This approach has many limitations. A more recent approach has been to systematically review charts looking for evidence of adverse events, which allows one to both measure the rate of harm, identify areas of greatest risk and then one can determine whether changes made are having any meaningful effect in reducing rates of harm.
A paper just published (free here) describes an alternative approach in which a trained observer directly measures rates and type of harm occurring. The authors found almost 14% of patients suffered at least one adverse event, and 6% of all patients suffered a preventable adverse event. Overall 33% of adverse events were judged to be preventable. The rate of harm varied widely by specialty with <2% of obstetric patients being harmed to 11% of medical and ICU patients being harmed. The severity of harm also varied, with almost 5% of cardiac ICU patients dying or being permanently disabled due to an AE.

IHI Forum

I am attending the annual IHI forum, in Orlando far away from the arctic conditions at home. Amazing stuff,  spending the day at a course devoted to paediatric patient safety, with talks from the worlds experts in this area. Steve Muething, Cincinnati Children's talks about developing a high reliability organization in healthcare. Matt Scanlon, Milwaukee, talks about human factors and measurements in paediatric safety. Anne Matlow, Sick kids Toronto talks about the major problem of diagnostic error in children, pointing out that diagnostic mistakes account for 13-20% of adverse events, but are more likely to be preventable and are more likely to cause serious harm or death. Paul Sharek, Stanford discussed medication safety, raising the provocative point that although a great deal of money has been devoted to improving medication safety,  medication errors account for 20% of all errors and a much smaller proportion of serous harm.

Preventable Harm, Redux

A commentary by the authors of the NEJM paper I referred to recently has just been published. Well worth reading.

Preventable Harm in Hospitalized Patients

Following on from my recent discussion about the use of trigger tools, a paper just published in the New England Journal reports the rate of preventable harm occurring in patients admitted to 10 North Carolina hospitals over a 6 year period. The authors used a validated trigger tool to analyze charts from 100 admissions per quarter.
The results are very alarming; despite a reputation as being a state that is very proactice in efforts to reduce harm, there was no reduction in harm over the study period. For every 100 admissions, there were 25 episodes of harm. It is important to point out that not every one of these episodes caused serious harm. 18% of patients were harmed as a result of medical care. 63% of these episodes were considered to be preventable. Of the harm episodes considered to be preventable, 26% caused permanent damage, were life threatening or caused or contributed to a patient death. overall 2.4% of harms caused or contributed to a patients death.
The most common errors arose from procedure complications, hospital acquired infections and medication errors.
This paper is a wake up call for the patient safety movement; despite much apparent and real progress over the past decade, it is a cause for concern that there has been no significant improvement in patient safety. There are likely many reasons for this; patient safety has not been a research priority, safety always involves a cultural shift within in heathcare which can be very difficult to achieve, and by not involving the younger generation of healthcare professionals, especially at their training stage, we are adding to the difficulty.

Trigger Tools

How should we measure the harm we cause in healthcare? One method, increasingly widely used, is a trigger tool. These are standardized and validated instruments with which one reviews a random selection of medical charts; when a "trigger" is identified that might signal a possible harmful occurrence, the chart is reviewed in more detail to determine whether harm did occur. There are two benefits; an organisation can measure the harm it is causing over time and take steps to reduce the harm, and second, measure its effectiveness in reducing harm over time. In contrast to conventional incident reporting, the rate of harm detected by these tools is 2-5 fold higher. For more reading, I would suggest the following; IHI and NHSIII