2001-2002 Grant Awards
James S. Todd Memorial Award for Patient Safety Research
Assessing Hospitals’ Use of Mandatory Error Reports for Quality Improvement and Error Reduction
Joel C. Cantor, ScD, CSHP, Kimberley S. Fox, MPA; Denise A. Davis, Dr.PH, MPA; Cara L. Cuite, MA; David M. Frankford, JD; Albert L. Siu, MD, MSPH; and, Andrea I. Kabcenell, RN, MPH
State-mandated medical error reporting in hospitals and other health care facilities has become common since the release of the Institute of Medicine’s report To Err is Human in 2000. In 2002, Rutgers Center for State Health Policy conducted an exploratory study funded by the National Patient Safety Foundation to assess hospitals’ use of mandatory medical error and adverse event reports in New York State. This system, called New York Patient Occurrence Reporting and Tracking System (NYPORTS), is one of the oldest and largest state-mandated hospital reporting systems in the country. Based on semi-structured telephone interviews with over 100 administrative and clinical leaders from a stratified random sample of 20 hospitals throughout New York State, the study investigated hospital leaders’ awareness and perceived purpose of the reporting system, the process by which hospitals collect and use this data, the barriers to use, and perceived value by hospital leaders and its impact on patient safety. The study also sought to identify key factors that either facilitated or limited the use of data from the mandatory reporting system within New York State hospitals.
This study, the first of its kind, found that state-mandated hospital adverse event reporting in New York was successful in raising awareness of patient safety among hospital leadership and promoting investigative processes of serious medical errors that hospitals have found to be useful. However, during the early years of the reporting system, hospitals did not appear to have been utilizing much of NYPORTS adverse event data because of insufficient comparative data feedback and lack of confidence in event reporting across hospitals. We generally did not observe variations in patterns of use across hospital types. Our primary findings instead demonstrate the influence that one’s position in a hospital’s administrative and leadership structure has for perceptions of this adverse event reporting system. This study suggests that well-designed, state-mandated reporting systems can have positive impacts in raising awareness and accountability within hospitals, but also points to some barriers and burdens that designers of next-generation error reporting systems should address.
Remote Analysis of the Surgical Environment: Measuring the Effect of Debriefing Attendings on Surgical Safety Factors
Reid B. Adams, MD, J. Forrest Calland, MD; Stephanie Guerlain, PhD; Bruce Schirmer, MD; R. Scott Jones, MD; Keith Littlewood, MD; and, Carl Lynch, MD
The investigators of this study utilized an institutionally developed, integrated, multi-media audio-visual and sensor data collection system (RATE, for Remote Analysis of Team Environments). Debriefing sessions, which followed evaluation of baseline team performance and Crew Resource Management (CRM)* training sessions, were held with the attending surgeon and his team after the surgical procedure and included discussion and critique using video clips of the operative case.
Preoperative briefing elements and optimal intra-operative communication practices increased in frequency after implementation of CRM training and debriefing sessions, and this effect was sustained over subsequent study cases for each surgical team. Case specific participant knowledge and awareness, evaluated from post case questionnaires, also improved after debriefing sessions.
This study demonstrated that debriefing sessions are an effective technique to positively influence surgical safety factors of attending surgeons and their team members.
Impact of Computerized Alerts and Reminders on Implementation of a Weight-Based Unfractionated Heparin Dosing Protocol
Anne Marie Greco, PharmD, NYPH; Michael I. Oppenheim, MD; Ferdinand Velasco, MD; Rudina Odeh-Ramadan, PharmD; and, Josephine Sollano, MPH
At New York-Presbyterian Hospital (NYPH), we have implemented, and are in the process of evaluating, an IT-based project to improve the management of patients receiving heparin therapy. The project is designed to assure that care at NYPH is compliant with nationally accepted weight-based heparin dosing guidelines.
NYPH is a 2400-bed multi-campus academic health center. NYPH has an Eclipsys Computerized Provider Order Entry (CPOE) system implemented throughout the hospital. For this project, we are taking advantage of the clinical decision support features available in Eclipsys.
Data about heparin orders, administrations and other medications will be extracted from Eclipsys. PTT and creatinine results to assess exclusion criteria will be extracted from the lab system. Information about co-morbid conditions and adverse outcomes will come from chart review and the administrative data warehouse.
We have completed designing the experimental and analytic plan. We have also completed several interventions and designed measurement system analysis to evaluate and ensure data integrity. We are currently moving forward with the data collection using these refined automated and manual data collection methodologies.
