Unintended Consequences &

Patient SafetyFriday, March 1, 2013Victoria Aceti Chlebus

Lecture 12

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AgendaUnintended ConsequencesWhat is Patient Safety? The Baker Study

◦Methodology◦Results◦Limitations◦How Health Informatics can help

Final Thoughts

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Unintended Consequences Unpredictable complications, issues or

challenges that arise from introducing a new technology.

Documented cases of unintended consequences:◦http

://www.oha.com/KnowledgeCentre/Library/CoronersReports/Documents/Negus%20Tefari%20Topey%20Inquest%20-%20Documentation,Health%20Records,Reporting.pdf

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Process of Entering & Retrieving Information

Communication & Coordination Process Errors

Not suitable human-computer interface

Cognitive overload◦ Structure◦ Fragmentation◦ Overcompleteness

Misrepresenting work as linear◦ Inflexibility◦ Urgency◦ Workarounds◦ Transfers

Misrepresenting communication as information transfer◦ Loss of feedback◦ Decision support overload◦ Catching errors

Unintended Consequences: Types

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Patient Safety

Indicators of Patient Safety:• Adverse events • Rate of infection (C.Diff, MRSA, VRE)• Mortality trends • Prevention practices (hand hygiene)

“The reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes”

(CIHI, 2007).

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Patient Safety Reporting

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Patient Safety Reporting: How do we Stack up?

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The Baker StudyGroup of researchers headed by BakerThere was little evidence of how safe patients

were in Canadian acute care centresBaker and colleagues looked specifically at

adverse events as an indicator of patient safetyGovernment of Canada funded Canada Patient

Safety Institute $50million over 5 yearsAimed to identify the type and frequency with

which adverse events occur in Canadian acute care facilities

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The Baker Study: MethodologyHarvard Medical School Methodology (1984)4 hospitals in 5 provinces (BC, AB, ON, PQ,

NS) – randomly selected patient charts 2 stage chart review process and 18 listed

inclusion criteriaReviewed by medical professionals

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The Baker Study: Results

Adverse events tended to happen more frequently in teaching hospitals than small or community hospitals

7.5% of hospital admissions resulted in adverse events,

37% of which could have been preventable.

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The Baker Study: Results

Adverse events occurred more frequently with surgical patients

Adverse events occurred more frequently with older patients

Most patients recovered from reaction within 6 months

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The Baker Study: LimitationsBudget constraints limited scope of studyLooked only at adult populationsExcluded obstetrics and psychiatryHuman subjectivity of medical reviewers

and not on a scale (length of stay & prevention)

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How informatics can helpBaker: Suggested that electronic medical records

would assist in future studies and in the development of quality improvement studies

Legibility of medication ordersComputerized order entry (reminders and alerts)Automated drug administration (bar codes &

“smart” IVs)

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How informatics can help?Beyond looking at the technologies, we have

to look at solutions by:◦Using data to look at what the largest

communication challenges are◦Looking at the issues instead of new

technology◦For example: most successful informatics in

recent years, Surgical checklist.

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Final ThoughtsIssues that arise from the integration of

informatics can cause high risk adverse eventsKnowledge of current statistics of adverse

event rates in Canada is the first step in tackling the issue.

Health informatics can help, but must look at the issue and not the ‘sexy’ technology.