Like their counterparts in other states, hospitals in Rhode Island have experienced their share of tragic outcomes based on medical errors, from mix-ups in medication administration to wrong-site surgeries. However, change is afoot in the state as data pertaining to events are more freely reported by hospital staff, aggregated, and shared by the institutions in a quest to support a strong commitment to patient safety, according to Mary Reich Cooper, MD, JD, senior vice president and chief of quality control for Lifespan Corp, a Providence-based, four-hospital system, and an assistant professor at Brown University.
That change, Cooper told attendees of a session held during the American College of Healthcare Executives’ 2011 Congress on Healthcare Leadership in Chicago this past March, comes through participation by all 13 of Rhode Island’s private hospitals in the GE-MERS National Patient Safety Organization (PSO) sponsored by GE Healthcare. The “MERS” stands for “medical event reporting system,” GE Healthcare's technology tool, which the hospitals are using to report and send event and related data to the PSO.
“All of these tragic outcomes are opportunities to do better next time, and, in turn, improve patient care, but only if data are aggregated” across institutions, noted Cooper, who was joined in her presentation by Kathy Martin, MBA, managing director, GE Healthcare Performance Solutions. Martin noted that GE-MERS joined a list of about 78 federally certified PSOs this past February, when the U.S. Agency for Healthcare Research and Quality ruled that it meets the terms of a 2005 law passed by Congress. The law paved the way for the formation of PSOs as groups that would collect and analyze data on mistakes, near-misses, and similar occurrences. However, a key stipulation of the law holds that information submitted to the PSO must remain confidential and, with a few limited exceptions, cannot be used in criminal, civil administrative, or disciplinary proceedings.
While hospitals’ participation in PSOs is voluntary, the direction was deemed the best course of action based on the belief that “until we standardized the reporting” and aggregated data with the PSO as a framework, “we wouldn’t be able to get where we needed to go,” Cooper said. Under the umbrella of their participation in the GE PSO, the hospitals began rolling out the MERS component in mid-2010. Cooper said the Web-based system met three key criteria: it was easy to use so hospital personnel would be more likely to enter data, improving compliance; its routing function would send reports automatically to managers and administrators, improving the speed of follow-up; and its color-coded dashboard would provide managers with clear visibility into the status of each event inquiry, improving transparency for each organization.
“We liked the fact that we would not be using new people or technology,” Cooper noted. “We used existing servers. The event reporting system is a Web-based model that can be installed right on hospital computers—great given that a number of our hospitals were converting from paper to electronic reporting for the first time.”
In the PSO model, reported data include events with adverse outcomes, events with “no patient harm,” “near-misses/good catches,” and "unsafe conditions." Patient safety work product attached to the data is captured as well. Data and work product are de-identified (that is, their source is rendered anonymous) and aggregated across all group participants. The de-identified information is then reported back to members, along with insights into trends. Data are also transmitted to the National Patient Safety Database, and services are offered to close any gaps.
Steps for Success
Cooper attributed a portion of the success and benefits wrought by the PSO to steps taken to ensure that its potential could be leveraged to a high degree. For example, she said, a concerted effort was made to define what would constitute events and near-misses, as well as to lay out set reporting roles and responsibilities. “We went beyond the common format to focus on patient safety events and employee events, especially employee events related to patients—for example, needle stick injuries,” she explained.
Just as significantly, concerted efforts were made to develop strategies for keeping hospital staff engaged and achieve clarity as to the type of information to be reported. Hospital staff were told that although reporting events and near-misses to the proper parties might indeed be part of their job responsibilities, the information needed to be entered into MERS. “We said that as a whole, ‘we don’t know what’s happening unless you tell us,’” Cooper explained.
A considerable amount of time also was devoted to organizing the PSO content into logical fields and relationships so that it would not become overwhelming for staff to execute reports. “In general, our training has focused on what we want people to report and how often, because as far as we are concerned, you cannot report enough,” Cooper asserted. She added that MD Anderson Cancer Center receives seven reports per bed, per month—“a phenomenal number” that affords front-line hospital personnel “an opportunity to change the way their work environment is structured” because of the wealth of information through which they can pinpoint areas warranting improvement and begin to effect change.
Big Benefits
As of the date of the presentation, the PSO had allowed the hospitals to identify more than 5,000 events, with Rhode Island Hospital alone generating 120 event reports per week.
While capturing events remains a critical function of the system, a vast majority of incidents reported are near-misses and unsafe conditions the hospitals have easily been able to rectify before they escalated, thereby enhancing patient safety. For example, Cooper said, “when staff in our endo suite noticed that our bowel prep had been changed to a cherry-flavored variety that coated the intestine so they could not tell what was the bowel prep and what was blood, it was reported and pulled across the system that afternoon.”
In particular, according to Cooper, the PSO is opening doors to a “tremendous” amount of previously unavailable data pertaining to infections, pharmacy services, and medication safety in general, as well as near-misses in medication administration. Root cause analyses (RCAs) are documented in MERS for sentinel events. Connections between events with common causality can be established because patient safety RCAs can utilize an integrated RCA tree to draw them. More generally, Cooper observed, the PSO is rendering the “opportunity for safety” increasingly comprehensive given that as clinicians and staff “start to see the response, they start to identify problems earlier and earlier. The PSO takes the feedback loop up to a whole new level. By aggregating the information, we start to understand problems. If you had told us when we had our first or second wrong-site surgery that this was happening 46 times a week across the U.S., we would not have believed you. It gives everyone a realistic understanding of how often these things are happening—and more importantly, serves as a platform for hospitals to learn from each other” as they work toward the common goal of enhanced patient safety.
Julie Ritzer Ross is a contributing writer for HealthCXO.com.