Administrative Memos

200218

FROM: Theodore O. Will, Chief Executive Officer
DATE: Nov 05, 2002
SUBJECT: Patient Safety Project
IPRO CONTACTS:

Alan Silver, MD, MPH., Clinical Coordinator, Project Leader, extension 445

Early, quick, and appropriate identification and response to potential patient injury is the key to patient safety. IPRO has developed several practical tools to help health care providers screen for possible adverse events and to standardize the method and process of conducting a Root Cause Analysis. This work was supported by the Centers for Medicare & Medicaid Services (CMS) and built from data reported into New York Patient Occurrence and Reporting System (NYPORTS). The tools are being distributed to all New York State hospitals. We suggest that you share the attached information with your Patient Safety Officer/Risk Manager.

The first tool is a computerized medical chart abstraction instrument designed to identify for several NYPORTS short and long form codes. Once cases are abstracted a data report can be generated at the click of a button. The instrument has been extensively tested on ~2700 Medicare surgical cases covering a broad array of case types (e.g., hip replacements, colon resections). The NYPORTS codes in the abstraction tool are:

201 - Aspiration Pneumonia
302 - Pulmonary edema
401 - Pulmonary embolism
402 - Deep vein thrombosis
501 - Unplanned laparoscopic conversions
601 - New central neurological deficit
602 - New peripheral neurological deficit
603 - Cardiac arrest w resuscitation
604 - Acute myocardial infarction
605 - Death occurring after procedure
801 - Procedure-related injury requiring repair, removal, etc
803 - Hemorrhage or hematoma
804 - Anastomotic leak requiring repair
805 - Wound dehiscence requiring repair
806 - Displacement migration, break of implant, device, graft, etc
807 - Thrombosis distal graft requiring repair
808 - Post-op wound infection
819 - Unplanned operation or re-operation related to primary procedure
911 - Wrong patient, site
912 - Incorrect procedure or invasive Rx
913 - Unintentionally retained foreign body
915 - Unexpected death
916 - Cardiac arrest with BCLS/ ACLS
917 - Loss of limb or organ
918 - Impairment of limb
919 - Loss or impairment of bodily function
920 - Errors of omission resulting in death or serious injury related to patient's underlying condition
937 - Malfunction of equipment during Rx or diagnosis or a defective product that resulted in death or serious injury

A second set of tools is designed to assist with Root Cause Analysis (RCA). IPRO has created a Trainers Guide, in a workbook format, detailing the steps involved in the root cause analysis process from team formation to action plan development and ongoing monitoring. The appendix includes tools, such as stakeholder analysis, force field analysis, and work plans, along with instructions and templates for their use.

IPRO also has developed a computer-guided RCA. The RCA System (RCAS) is designed to help the user document the sequence of events that lead up to the adverse event, evaluate the role of each step, and identify root causes. RCAS builds on questions developed by the Veteran's Administration National Center for Patient Safety and targets the areas of:

Human Factors: Fatigue
Human Factors: Communication
Human Factors: Training
Equipment and Environment
Rules, Policies and Procedures
Barriers

RCAS is a database that can be used to examine patterns of root cause analysis performed within an institution. Another valuable feature of RCAS is that it provides output that can be used for reporting and documentation. Please note, RCAS does not replace NYPORTS reporting, nor does it directly interface with NYPORTS. We believe it will help you perform a RCA more effectively by employing a proven taxonomy that is used in over 170 Veteran's Administration hospitals.

Enclosed you will find a packet of documents and a compact disc for the Patient Safety Project containing the following materials.

Compact Disc:

Patient Safety Medical Chart Abstraction Tool
RCA Paper Toolkit
RCAS application

Hard Copy Documents:

RCA Paper Tool Kit

Please take the time to carefully review the information and materials. We hope you find the materials provided for the Patient Safety Project to be beneficial and informative in your continued efforts to improve the quality of care delivered to patients.

Should you have any questions concerning this memorandum or require additional information, please contact Alan Silver, MD, MPH, Clinical Coordinator/Project Leader, at extension 445.