Physicians News Health news for doctors and patients.
By Tom Lundquist, M.D.
As health care providers in the ambulatory setting, can we ensure, when our most complicated patients undergo surgery, that they will emerge safely? What if the patient is healthy and undergoing an elective procedure such as PE tube placement or sinus surgery? Can we ensure that when we send patients for laboratory tests, they will be safe and that the results will be communicated appropriately so as to prevent patient harm? When we write for a common medication, are we certain that we have taken every precaution possible to ensure that the medication is truly safe, to the best of our knowledge, for the recipient?
Last summer, the Center for Information Technology Leadership (CITL), a research organization in Boston, conducted a study of information technology in the ambulatory setting. Early data suggest that major problems in hospitals, such as medical errors, are equally as large in outpatient venues.
Errors happen. In our daily attempt to deliver the best care to our patients, mistakes do occur and largely because of the complex processes within which we work. Near misses occur each day and they are just as frequent in the outpatient arena as they are within hospitals. In fact, for the average physician seeing 200+ patients each week, the potential for adverse events to affect his/her patient becomes a frightening reality. Luckily, most events are not harmful and could be classified as near misses.
Multiple persons in the outpatient setting might interact with patients during a visit and in follow-up. Physicians, nurse practitioners, physician assistants, nurses, medical assistants and even the front office staff might be the first to be made aware of adverse events, errors and near misses. Do they have the tools necessary to document concerns and/or events so that they can be reviewed properly and in real time?
Take the more than 100,000 adverse clinical events, medication errors, administrative events, and falls aggregated in our national aggregate database. A subset of the database comes from ambulatory care practices affiliated with hospital systems. The lessons learned are applicable to all practices, whether physician-owned or hospital-owned.
A review of our database reveals that 34 percent of the events reported are in the category of medication errors:
One of the most important insights from our national database is that medication errors account for only one-third of the total errors. One area that gets very little attention, for example, is the lab error. Our database shows that over 10 percent of the total adverse outcomes that are reported are due to lab error. Most of the laboratory events (5774 or nearly 60 percent) reported in our database were reported as near misses or no harm/no monitoring. However, there are clusters of events in certain event classifications which raise concern.
• Critical results were not reported in 241 events, of which one case listed death as the outcome and of which nine cases resulted in permanent harm.
• Delay in test/treatment resulted from lab issues in 621 reported events, 80 cases of which resulted
in temporary harm, six of which permanent harm or near death resulted, and one of which reported death as the outcome.
Such data may lead physicians in an ambulatory care setting to consider reviewing laboratory processes, as well as reporting turnaround time, critical result notification and patient follow-up procedures. Many realize that gaps exist, especially with certain vendors. Without aggregate data allowing for the review of near misses, however, it is sometimes difficult to improve processes until adverse events unfortunately occur.
Our clients in the ambulatory care arena are finding that it is just as important for them to track medical errors as it is for a hospital to do so. They have found that knowledge about medication problems as well as lab errors can be very crucial to improving patient safety. Furthermore, by harnessing the power of online, real-time, web-based systems, doctors have found that they can address safety problems before they turn into major litigation issues. Without implementing expensive technologies, practices have been able to make improvements, just by knowing where the opportunities lie.
An electronic medical error tracking system takes the user through the process in a way that rewards us with the necessary data in a consistent format. If you enter “medication error,” such a system can be designed to prompt for the kind of error, what kind of follow up treatment, where the error occurred, who was present and a host of other information. The prompts posed are dependent on the information provided. The data requirements are consistent and therefore quite valuable to organizations looking to benchmark and learn from other organizations’ experiences.
Furthermore, an electronic medical error tracking system allows for easier quality control over multiple and disparate facilities, often located miles apart from one another.
Users of electronic medical error tracking systems have reported other benefits as well, in addition to improving patient safety.
• Clients find that the time required to track errors and make improvements is usually reduced 25 to 50 percent by eliminating the routing of paper and by making reports immediately available to managers online.
• Entering information in the system is easy for staff – no searching for forms and no worries about interruptions in completing the form, since it takes on average just two to three minutes to complete, but it can also be saved and completed later in a password-protected environment.
• Event reports submitted electronically are HIPAA compliant and far more secure than paper-based systems, which require manual transfer of sensitive data from desk to desk.
• Event reports are kept separate from the medical record, allowing for proper peer review protection during the process improvement effort – in compliance with many state laws.
• The immediacy of an electronic medical error tracking system ensures that not a minute is lost: follow-up to problems can happen immediately, because automatic alerts are sent to all appropriate managers.
Ideally, an organization will harness the power of the Web to track errors. The Web provides real-time benefits that a mainframe server-based system simply can’t. Most good Web systems are in the application service provider (ASP) framework, which means that the provider need only “turn on” the system through signing up for its use.
Most ambulatory care settings lack the resources of an experienced IT department. But even if one exists, proprietary programs can bog down the IT resources, leaving IT staff no choice but to call in vendors to help. The ASP model provides the greatest reach, creating a view that encompasses all the units of a system, but can also allow for an individualized view. Using an ASP model, all that is required of the physician’s office, is a standard desktop computer running 5.x in Netscape.
Although a dedicated server is not necessary with an ASP model, a network of computers is very helpful, as reporting is more likely to happen when a computer is within reach of each staff member.
If you use such an outsourced solution, be sure its architecture is highly configurable, customizable, scalable and flexible (CCSF). Beyond being Web-based, other factors drive CCSF.
Make sure to ask about the vendor’s national hosting partnership. Your system needs to be accessible and available. Ask about downtime, how often it has occurred and what measures were taken to prevent it in the future. Ask for documentation and proof points regarding reliability. Also, a Web-based system should leverage advanced information exchange benefits, such as those benefits from platforms like .NET.
The system should feature an advanced question engine, because acute care, behavioral health, rehabilitation, etc. have very different types of questions and prompts relevant to their practices. The question engine should have a natural build so that every question is relevant, with the respondent’s answer leading to the next question. This brings forth the most relevant data. Also, the question/answer sets should evolve over time, so that the surveying method allows for seamless change as processes and policies change.
The permissions capability should be advanced. Make sure that the system will fit with your specific facility requirement regarding work-flow on follow-up, feedback, recommendations and chain of command. Any additions/edits to the event entry as well as analysis and conclusions, should be tracked and all original entries should be kept for future reference and follow-up.
Make sure the system allows for easy downloads of the data onto hard-drives. Your data is yours, and shouldn’t be difficult to extract should you ever need to end relations with your vendor. Make sure the product is well architected and therefore supports exporting on a database-ready and/or desktop-application ready format, whether it be a SQL server database to an Excel spreadsheet.
The system should have an offline complementary form: a paper back-up form that mirrors the online service will ensure consistency when a computer isn’t available to a staff member.
Be sure your outsourced medical error tracking solution provides training to support the staff orientation, a more dense view of the product for managers, as well as site administrator training. Even with an ASP-based model, there should be a training component in place. Depending on the class audience, the training should cover:
• How to set up permissions.
• How to customize.
• Ideas for engaging a patient safety culture.
• How to run a ground level analysis.
• User guides.
Under HIPAA and other requirements, security for an electronic medical error tracking system should be a major focus. When choosing a system, be sure to find one that takes a multi-tiered approach to security, including:
• Physical security. Video surveillance of the facilities that hold the data (network operations centers), card key access and security staff should be included.
• Electronic security. Every piece of data that is moved over the Internet must be encrypted. Good systems will feature supported point-to-point VPN, state-of-the-art fire-walling, and intrusion detection capabilities. All resources working with your vendor should sign confidentiality agreements and should undergo HIPAA training.
• Operational security. Personnel, policy and procedures should be in place to ensure the utmost in security. Look for an organization that has been HIPAA audited and approved, and make sure that your vendor can prove independent verification of steps taken to ensure security.
Some solutions will be easy. We have seen facilities greatly reduce errors related to sound-alike and look-alike drugs, for example, simply by changing how the drugs are stored. Other issues will require more strategizing, through a team approach.
When a trend in patient safety issues is detected by the electronic medical error tracking system, it is important to follow up. Few vendors provide the option of consulting with a CMO and/or knowledgeable account manager, who can help to develop a set of countermeasures and strategies for improvement. A system that includes this option could very valuable.
A very limited number of medical error tracking systems feature the ability to provide comparative data regarding process improvement. This can be a boon to organizations looking to put their performance into perspective. For example, we predict that some health care practices will improve their quality initiatives because they are not stacking up to comparable organizations in other regions. This will come with an accumulation of data.
Our clients have begun to teach us many things. First, they have confirmed the common understanding that errors are usually not caused because of a particular individual but rather because of poor processes (e.g., lack of proper reminder systems or feedback mechanisms). Second, in the majority of cases, more than one individual is involved in the care of the affected patient and more than one individual holds the key to successful improvement of the care process. Third, unless near misses are looked at in a blame-free environment, fear and secrecy surround them, rather than a proactive, process improvement-driven culture.
When it comes to patient safety, there is no room for fear, but certainly room for improvement. Any organization, large or small, that pays attention to culture, capture of data, information sharing and applicable solutions will find that the patient safety journey will likely lead to success.
Tom Lundquist, M.D., is Chief Medical Officer at DoctorQuality, Inc., Conshohocken, Pennsylvania.
