ROOT CAUSE ANALYSIS &
HOSPITAL-ACQUIRED VTE
Artemis Diamantouros, Lynn Riley,
Valentine Valenzuela, Bill Geerts
April 16th...
Welcome to our francophone attendees
Bienvenue à nos participants
francophones
Hélène Riverin
Conseillère en sécurité et e...
Objectives
By the end of this call, you will be able to:
1. Describe the processes of Root-Cause Analysis
(RCA) and Multi-...
Today’s Speakers
Bill Geerts Artemis DiamantourosLynn Riley Valentine Valenzuela
Agenda
1. Brief primer on root cause analysis (RCA)
2. Measuring performance in VTE prevention
3. Using RCA in VTE prevent...
Root Cause Analysis
(also called Incident Analysis)
Lynn Riley, RN
ISMP Canada
ISMP Canada
ISMP Canada is an independent not-for-profit
organization dedicated to reducing preventable
harm from medicati...
www.cmirps-scdpim.ca
ISMP Canada
How can we analyze incidents
effectively?
Canadian Incident Analysis
Framework (CIAF) 2012
•Updated from Canadian Root
Cau...
Gather
information
Analyze
information
Identify contributing
factors
Develop and prioritize
recommended actions
What
happe...
The Incident Management
Continuum
Incident Analysis Methods
Individual Incident Analysis
• Analysis of an individual incident with the goal
of identifying u...
Qualitative Analysis Strategies
Described in the Canadian
Incident Analysis Framework
Multi – Incident Analysis:
- Analysi...
As Part of the CQI Program
Multiple-Incident Analysis can contribute to two key
steps in the CQI process:
- Identify the h...
Two Complementary Approaches
Quantitative Analysis (“numbers”)
- Summarize medication incident data
- Descriptive statisti...
Summary of Medication
Incident Analysis Strategies
Medication
Incident Data
Quantitative
Analysis
Qualitative Analysis
Ind...
Multi-Incident Analysis:
7 Step Process
Summary
Multi-Incident Analysis: Analysis of the narrative data
fields on a group of reports involving a common pre-
defin...
ISMP Canada Workshops
May 20, 2015 Multi-Incident Analysis Workshop –
Toronto
May 22, 2015 Incident Analysis Framework: Tr...
Tools
The Hospital Self-Assessment for
Anticoagulant Safety (HSASAS) is designed
to:
Heighten awareness of best practices ...
We encourage you to report
medication incidents
Practitioner Reporting
https://www.ismp-canada.org/err_report.htm
Consumer...
Thank you
Lynn Riley
lriley@ismp-canada.org
2. Measuring performance in
VTE prevention
Bill Geerts, MD, FRCPC
Thrombosis Consultant, Sunnybrook Health
Sciences Centre...
Assessing the success of
VTE prevention programs
 Essential to measure the impact of patient
safety/QI efforts
Two types ...
Advantages of auditing adherence
 Simple, fast, inexpensive
 Can largely be done with EPR, electronic pharmacy
records
...
Unit
type
Total no. patients No. pts excluded Prophylaxis
indicated
Appropriate*
prophylaxis ordered
2012 2013 2014 2015 2...
Limitations of auditing adherence
 Usually limited in scope (single unit/service)
 Usually 1-time snapshots of care
 Us...
Assessing the success of
VTE prevention programs
 Essential to measure the impact of patient
safety/QI efforts
Two types ...
Methodology of clinical outcome audits
1. Retrospective health records data
2. Real time prospective case finding
3. Real ...
2 types of real-time HA-VTE audits
1. All events (research study)
- very time consuming
2. Representative events (QI initi...
Limitations of auditing clinical outcomes
(VTE)
 Difficult to find all cases of HA-VTE
 Resource intensive to find cases...
Sunnybrook’s approach
1. Retrospective health records data
2. Real time prospective case finding
3. Real time case finding...
3. Using RCA in VTE prevention
quality improvement
Val Valenzuela, RN
Thrombosis nurse, Sunnybrook HSC
Artemis Diamantouro...
Methods
 Case finding: Medical Imaging list of positive leg Dopplers
+ daily Thromboembolism Service
 Cases: symptomatic...
Symptomatic Hospital-Acquired DVT/PE
(>2 days after adm to 2 months after discharge)
Appropriate*
thromboprophylaxis
Subop...
Hospital-Acquired DVT/PE 2011-14
(n= 198; 4.7/month)
Appropriate*
thromboprophylaxis
(133 = 67%)
Suboptimal*
thromboprophy...
0
5
10
15
20
25
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
U-VTE
P-VTE
Hospital-Acquired VTE by Month
(2011-14)
Total...
0
5
10
15
20
25
30
Hospital-Acquired VTE by Nursing Unit
(2011-14)
Total/nursing unit:
3 1 2 4 14 1 5 18 38 23 2 2 3 0 2 3...
0
5
10
15
20
25
30
35
Series
1
Series
2
Hospital-Acquired VTE by Clinical Service
(2011-14)
U-VTE
P-VTE
Total/clinical ser...
GynOnc GenSur NS Ortho Traum MedOnc CarSur GIM Cardio 2011-13
1.6%
1.4%
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
0
Adm 1,036 3,148 1,...
Potentially Preventable HA-VTE
 65 potentially preventable HA-VTE, July 2011 – Dec 2014
22 (34%)
18 (28%)
15 (23%)
4 (6%)...
Limitations of this type of HA-VTE audit
 Underestimates true HA-VTE rates
- OK = we’re not trying to find all events
 T...
Benefits of this type of HA-VTE audit
 Identifies clinically-relevant outcomes (“real
patients harmed”)
 Provides insigh...
Mrs. Jones.
Take Home Messages
 Root cause analysis is a powerful quality
improvement tool
- Individual incident
- Multi-incident
 R...
“Taking the Pulse” Poll / Sondage
Instructions to download certificate
1
2 3
4
5
8
9
Thank you!
 Questions; comments/suggestions
 How can Safer Healthcare Now!
help you?
Artemis Diamantouros 416-480-6100 x...
Your Patient Had A VTE – What Went Wrong?
Your Patient Had A VTE – What Went Wrong?
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Your Patient Had A VTE – What Went Wrong?

Objectives: By the end of this call, you will be able to: •Describe the processes of Root-Cause Analysis (RCA) and Multi-Incident Analysis (MIA) and their role in quality improvement •Compare and contrast the different approaches to collecting hospital-acquired VTE data •Identify an approach suitable for improving patient safety at your institution
Published on: Mar 3, 2016
Published in: Healthcare      
Source: www.slideshare.net


Transcripts - Your Patient Had A VTE – What Went Wrong?

  • 1. ROOT CAUSE ANALYSIS & HOSPITAL-ACQUIRED VTE Artemis Diamantouros, Lynn Riley, Valentine Valenzuela, Bill Geerts April 16th, 2015 “Your patient had a VTE – what went wrong?”
  • 2. Welcome to our francophone attendees Bienvenue à nos participants francophones Hélène Riverin Conseillère en sécurité et en amélioration Safety Improvement Advisor
  • 3. Objectives By the end of this call, you will be able to: 1. Describe the processes of Root-Cause Analysis (RCA) and Multi-Incident Analysis (MIA) and their role in quality improvement 2. Compare and contrast the different approaches to collecting hospital-acquired VTE data 3. Identify an approach suitable for improving patient safety at your institution
  • 4. Today’s Speakers Bill Geerts Artemis DiamantourosLynn Riley Valentine Valenzuela
  • 5. Agenda 1. Brief primer on root cause analysis (RCA) 2. Measuring performance in VTE prevention 3. Using RCA in VTE prevention quality improvement
  • 6. Root Cause Analysis (also called Incident Analysis) Lynn Riley, RN ISMP Canada
  • 7. ISMP Canada ISMP Canada is an independent not-for-profit organization dedicated to reducing preventable harm from medications. Our goal is the creation of safe and reliable systems for managing medications in all environments. www.ismp-canada.org
  • 8. www.cmirps-scdpim.ca
  • 9. ISMP Canada
  • 10. How can we analyze incidents effectively? Canadian Incident Analysis Framework (CIAF) 2012 •Updated from Canadian Root Cause Analysis (RCA) Framework (2006) •Developed collaboratively by CPSI, ISMP Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI), and with assistance from Paula Beard, Carolyn Hoffman and Micheline Ste-Marie
  • 11. Gather information Analyze information Identify contributing factors Develop and prioritize recommended actions What happened? Why did it happen? What can be done to reduce the likelihood of recurrence? Implement, Evaluate, Share Learning What has been learned?
  • 12. The Incident Management Continuum
  • 13. Incident Analysis Methods Individual Incident Analysis • Analysis of an individual incident with the goal of identifying underlying systems based contributing factors. • Includes Comprehensive Analysis and Concise Incident Analysis Multi-Incident Analysis • Analysis of a group of reports involving common factors pre-defined for achieving a specific objective
  • 14. Qualitative Analysis Strategies Described in the Canadian Incident Analysis Framework Multi – Incident Analysis: - Analysis of a group of reports involving common factors pre- defined for achieving a specific objective - Method of reviewing several incidents at once instead of one- by-one, by grouping them in themes (in terms of composition or origin) - No, low, or medium harm severity (or near misses) - Generates valuable organizational and/or system-wide learning that cannot be obtained through other methods Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute; 2012. Incident Analysis Collaborating Parties are Canadian Patient Safety Institute (CPSI), Institute for Safe Medication Practices Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn E. Hoffman and Micheline Ste-Marie.
  • 15. As Part of the CQI Program Multiple-Incident Analysis can contribute to two key steps in the CQI process: - Identify the high impact areas for improvement - Facilitate the development of effective system and process enhancements
  • 16. Two Complementary Approaches Quantitative Analysis (“numbers”) - Summarize medication incident data - Descriptive statistics (e.g. frequency distribution tables) Qualitative Analysis (“narratives”) - Analysis of narrative data (“the stories”) - Qualitative research methods - Individual Incident Analysis & Multi-Incident Analysis
  • 17. Summary of Medication Incident Analysis Strategies Medication Incident Data Quantitative Analysis Qualitative Analysis Individual Incident Analysis (Comprehensive & Concise) Multi-Incident Analysis
  • 18. Multi-Incident Analysis: 7 Step Process
  • 19. Summary Multi-Incident Analysis: Analysis of the narrative data fields on a group of reports involving a common pre- defined factor Maximizes analysis efficiency (analysis of a group of incidents at a time) 7 Step Process
  • 20. ISMP Canada Workshops May 20, 2015 Multi-Incident Analysis Workshop – Toronto May 22, 2015 Incident Analysis Framework: Train-the- Trainer Workshop (For PSEP – Canada Trainers in Ontario LHIN 14) - Thunder Bay, ON June 11-12, 2015 RCA/FMEA for pharmacy practice - Toronto Request a Customized RCA/Incident Analysis Workshops in English or French education@ismp-canada.org
  • 21. Tools The Hospital Self-Assessment for Anticoagulant Safety (HSASAS) is designed to: Heighten awareness of best practices with respect to anticoagulant safety Create a baseline for hospital efforts to enhance the safety of anticoagulant use and assess progress with respect to these strategies and practices over time. https://mssa.ismp-canada.org/hsasas
  • 22. We encourage you to report medication incidents Practitioner Reporting https://www.ismp-canada.org/err_report.htm Consumer Reporting www.safemedicationuse.ca/
  • 23. Thank you Lynn Riley lriley@ismp-canada.org
  • 24. 2. Measuring performance in VTE prevention Bill Geerts, MD, FRCPC Thrombosis Consultant, Sunnybrook Health Sciences Centre; Professor of Medicine, University of Toronto; National Lead, VTE Prevention, Safer Healthcare Now!
  • 25. Assessing the success of VTE prevention programs  Essential to measure the impact of patient safety/QI efforts Two types of outcomes: 1. Process measures - % of patients at risk for VTE who receive appropriate thromboprophylaxis 2. Clinical measures – DVT, PE, complications
  • 26. Advantages of auditing adherence  Simple, fast, inexpensive  Can largely be done with EPR, electronic pharmacy records  Apply standard rules for eligibility, acceptable thromboprophylaxis options  Can audit the entire hospital  Can compare units/services + over time  Can compare to other centres
  • 27. Unit type Total no. patients No. pts excluded Prophylaxis indicated Appropriate* prophylaxis ordered 2012 2013 2014 2015 2012 2013 2014 2015 2012 2013 2014 2015 2012 2013 2014 2015 All surgical units 221 233 223 199 46 30 37 57 175 203 186 142 86 % 93% 96% 90% All medical units 207 187 210 209 54 43 63 72 153 144 147 137 78 % 90% 87% 92% All major ICUs 44 42 51 48 11 6 9 13 33 36 42 35 94 % 94% 98% 91% All acute care units 472 462 484 456 111 79 109 142 361 383 375 314 301 (83%) 351 (92%) 347 (93%) 286 (91%) Appropriate* Prophylaxis by Unit Groups *defined as consistent with Sunnybrook policy
  • 28. Limitations of auditing adherence  Usually limited in scope (single unit/service)  Usually 1-time snapshots of care  Usually don’t audit “optimal” prophylaxis but rather “any” or “on the list” prophylaxis  If local policy is not optimal, good adherence may not  improved outcomes  Surrogate for clinically-important outcomes  Often targets the wrong audience e.g. RNs, pharmacists rather than the order writers  Questionable impact on providers
  • 29. Assessing the success of VTE prevention programs  Essential to measure the impact of patient safety/QI efforts Two types of outcomes: 1. Process measures - % of patients at risk for VTE who receive appropriate thromboprophylaxis 2. Clinical measures – DVT, PE, complications
  • 30. Methodology of clinical outcome audits 1. Retrospective health records data 2. Real time prospective case finding 3. Real time case finding + feedback
  • 31. 2 types of real-time HA-VTE audits 1. All events (research study) - very time consuming 2. Representative events (QI initiative) 1 2
  • 32. Limitations of auditing clinical outcomes (VTE)  Difficult to find all cases of HA-VTE  Resource intensive to find cases, review details, do root cause analysis  Many HA-VTE occur after discharge  Relatively small numbers per unit - may be “underwhelmed” by results
  • 33. Sunnybrook’s approach 1. Retrospective health records data 2. Real time prospective case finding 3. Real time case finding + feedback  Let’s try to find as many symptomatic, proven HA-VTE cases as we can  Try to find them ASAP after the diagnosis  Do a root cause analysis on these cases  All the identified cases of HA-VTE go into a database  Provide timely feedback to the care team if thromboprophylaxis wasn’t optimal
  • 34. 3. Using RCA in VTE prevention quality improvement Val Valenzuela, RN Thrombosis nurse, Sunnybrook HSC Artemis Diamantouros, BScPhm, PhD Knowledge Translation pharmacist, Sunnybrook HSC; National Coordinator VTE Prevention, Safer Healthcare Now! VTE QI in real time
  • 35. Methods  Case finding: Medical Imaging list of positive leg Dopplers + daily Thromboembolism Service  Cases: symptomatic, confirmed DVT or PE >2 days after admission and <2 months after discharge  Standardized root cause analysis of causative and contributing factors for the event  Did the patient receive appropriate thromboprophylaxis as per Sunnybrook policy? 1. Potentially preventable VTE: written feedback to the patient’s care team 2. “Unpreventable VTE”: enter into HA-VTE database
  • 36. Symptomatic Hospital-Acquired DVT/PE (>2 days after adm to 2 months after discharge) Appropriate* thromboprophylaxis Suboptimal* thromboprophylaxis (=potentially preventable) Root cause analysis (causative/contributing factors) Provide feedback to the care team Enter into database Review our VTE Policy & Guidelines *according to Sunnybrook’s Thromboprophylaxis Policy and Guidelines Excl: upr extrem, abd, CNS, incidental
  • 37. Hospital-Acquired DVT/PE 2011-14 (n= 198; 4.7/month) Appropriate* thromboprophylaxis (133 = 67%) Suboptimal* thromboprophylaxis (=potentially preventable) (65 = 33%) Root cause analysis Provide feedback to the care team Enter into database Review our VTE P&G 1.5/mo *according to Sunnybrook’s Thromboprophylaxis Policy and Guidelines
  • 38. 0 5 10 15 20 25 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec U-VTE P-VTE Hospital-Acquired VTE by Month (2011-14) Total/month: 15 12 13 10 12 14 20 29 26 16 18 13
  • 39. 0 5 10 15 20 25 30 Hospital-Acquired VTE by Nursing Unit (2011-14) Total/nursing unit: 3 1 2 4 14 1 5 18 38 23 2 2 3 0 2 3 21 33 5 1 1 5 3 6 0 2
  • 40. 0 5 10 15 20 25 30 35 Series 1 Series 2 Hospital-Acquired VTE by Clinical Service (2011-14) U-VTE P-VTE Total/clinical service: 3 1 0 0 18 48 16 1 17 1 0 24 0 0 28 2 3 5 1 1 0 22 7 0
  • 41. GynOnc GenSur NS Ortho Traum MedOnc CarSur GIM Cardio 2011-13 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0 Adm 1,036 3,148 1,536 1,757 2,066 2,852 1,285 8,761 2,591 31,106 HA- VTE 14 37 15 13 15 14 2 10 0 137 1.35% 1.18% 0.98% 0.74% 0.73% 0.49% 0.16% 0.11% 0 0.44% Hospital-Acquired VTE by Clinical Service (2011-13)  Services with >1000 admissions
  • 42. Potentially Preventable HA-VTE  65 potentially preventable HA-VTE, July 2011 – Dec 2014 22 (34%) 18 (28%) 15 (23%) 4 (6%) 3 (5%) 2 (3%) 4 (6%) 34% 28% 23% 6% 5% 3%2% Incorrect dose Inappropriate delay No prophylaxis given TEDs use suboptimal Inadequate duration Suboptimal compliance Other
  • 43. Limitations of this type of HA-VTE audit  Underestimates true HA-VTE rates - OK = we’re not trying to find all events  Time consuming to find as many cases as is “reasonable” - 30-60 minutes/week
  • 44. Benefits of this type of HA-VTE audit  Identifies clinically-relevant outcomes (“real patients harmed”)  Provides insights not seen with other audit methods  Real-time feedback (the care team will know/remember the patient)  Complements audits of adherence  Can inform changes in policies and guidelines
  • 45. Mrs. Jones.
  • 46. Take Home Messages  Root cause analysis is a powerful quality improvement tool - Individual incident - Multi-incident  RCA can be used in VTE prevention QI  Provides unique insights into care and can be used to help change culture  Keep up the great work – clots can be beaten!
  • 47. “Taking the Pulse” Poll / Sondage
  • 48. Instructions to download certificate 1 2 3 4 5 8 9
  • 49. Thank you!  Questions; comments/suggestions  How can Safer Healthcare Now! help you? Artemis Diamantouros 416-480-6100 x 3654 Email: artemis.diamantouros@sunnybrook.ca Bill Geerts Email: william.geerts@sunnybrook.ca

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