Your Patient Had A VTE – What Went Wrong?

ROOT CAUSE ANALYSIS &

HOSPITAL-ACQUIRED VTE

Artemis Diamantouros, Lynn Riley,

Valentine Valenzuela, Bill Geerts

April 16th, 2015

“Your patient had a VTE – what went wrong?”

Welcome to our francophone attendees

Bienvenue à nos participants francophones Hélène Riverin Conseillère en sécurité et en amélioration Safety Improvement Advisor

Objectives

By the end of this call, you will be able to:

1. Describe the processes of Root-Cause Analysis

(RCA) and Multi-Incident Analysis (MIA) and their

role in quality improvement

2. Compare and contrast the different approaches to

collecting hospital-acquired VTE data

3. Identify an approach suitable for improving patient

safety at your institution

Today’s Speakers

Bill Geerts Artemis Diamantouros Lynn Riley Valentine Valenzuela

Agenda

1. Brief primer on root cause analysis (RCA)

2. Measuring performance in VTE prevention

3. Using RCA in VTE prevention quality improvement

Root Cause Analysis (also called Incident Analysis)

Lynn Riley, RN

ISMP Canada

ISMP Canada

ISMP Canada is an independent not-for-profit organization dedicated to reducing preventable harm from medications.

Our goal is the creation of safe and reliable systems for managing medications in all environments.

www.ismp-canada.org

www.cmirps-scdpim.ca

ISMP Canada

How can we analyze incidents effectively?

Canadian Incident Analysis Framework (CIAF) 2012

•Updated from Canadian Root Cause Analysis (RCA) Framework (2006)

•Developed collaboratively by CPSI, ISMP Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI), and with assistance from Paula Beard, Carolyn Hoffman and Micheline Ste-Marie

Gather

information

Analyze

information

Identify contributing

factors

Develop and prioritize

recommended actions

What

happened?

Why did it

happen?

What can

be done to

reduce the

likelihood of

recurrence?

Implement, Evaluate,

Share LearningWhat has

been

learned?

The Incident Management Continuum

Incident Analysis Methods

Individual Incident Analysis • Analysis of an individual incident with the goal

of identifying underlying systems based contributing factors.

• Includes Comprehensive Analysis and Concise Incident Analysis

Multi-Incident Analysis • Analysis of a group of reports involving

common factors pre-defined for achieving a specific objective

Qualitative Analysis Strategies Described in the Canadian Incident Analysis Framework

Multi – Incident Analysis:

- Analysis of a group of reports involving common factors pre-defined for achieving a specific objective

- Method of reviewing several incidents at once instead of one-by-one, by grouping them in themes (in terms of composition or origin)

- No, low, or medium harm severity (or near misses)

- Generates valuable organizational and/or system-wide learning that cannot be obtained through other methods

Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute; 2012. Incident Analysis Collaborating Parties are Canadian Patient Safety Institute (CPSI), Institute for Safe Medication Practices Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn E. Hoffman and Micheline Ste-Marie.

As Part of the CQI Program

Multiple-Incident Analysis can contribute to two key steps in the CQI process:

- Identify the high impact areas for improvement

- Facilitate the development of effective system and process enhancements

Two Complementary Approaches

Quantitative Analysis (“numbers”)

- Summarize medication incident data

- Descriptive statistics (e.g. frequency distribution tables)

Qualitative Analysis (“narratives”)

- Analysis of narrative data (“the stories”)

- Qualitative research methods

- Individual Incident Analysis & Multi-Incident Analysis

Summary of Medication Incident Analysis Strategies

Medication Incident Data

Quantitative Analysis

Qualitative Analysis

Individual Incident Analysis

(Comprehensive &

Concise)

Multi-Incident Analysis

Multi-Incident Analysis: 7 Step Process

Summary

Multi-Incident Analysis: Analysis of the narrative data fields on a group of reports involving a common pre-defined factor

Maximizes analysis efficiency (analysis of a group of incidents at a time)

7 Step Process

ISMP Canada Workshops

May 20, 2015 Multi-Incident Analysis Workshop – Toronto

May 22, 2015 Incident Analysis Framework: Train-the-Trainer Workshop (For PSEP – Canada Trainers in Ontario LHIN 14) - Thunder Bay, ON

June 11-12, 2015 RCA/FMEA for pharmacy practice - Toronto

Request a Customized RCA/Incident Analysis Workshops in English or French

[email protected]

Tools

The Hospital Self-Assessment for Anticoagulant Safety (HSASAS) is designed to:

Heighten awareness of best practices with respect to anticoagulant safety

Create a baseline for hospital efforts to enhance the safety of anticoagulant use and assess progress with respect to these strategies and practices over time.

https://mssa.ismp-canada.org/hsasas

We encourage you to report medication incidents

Practitioner Reporting https://www.ismp-canada.org/err_report.htm Consumer Reporting www.safemedicationuse.ca/

Thank you

Lynn Riley

[email protected]

2. Measuring performance in

VTE prevention

Bill Geerts, MD, FRCPC

Thrombosis Consultant, Sunnybrook Health

Sciences Centre;

Professor of Medicine, University of Toronto;

National Lead, VTE Prevention, Safer Healthcare Now!

Assessing the success of

VTE prevention programs

Essential to measure the impact of patient

safety/QI efforts

Two types of outcomes:

1. Process measures - % of patients at risk for VTE

who receive appropriate thromboprophylaxis

2. Clinical measures – DVT, PE, complications

Advantages of auditing adherence

Simple, fast, inexpensive

Can largely be done with EPR, electronic pharmacy

records

Apply standard rules for eligibility, acceptable

thromboprophylaxis options

Can audit the entire hospital

Can compare units/services + over time

Can compare to other centres

Unit

type

Total no. patients

No. pts excluded

Prophylaxis

indicated

Appropriate*

prophylaxis ordered

2012

2013

2014

2015

2012

2013

2014

2015

2012

2013

2014

2015

2012

2013

2014

2015

All

surgical

units

221 233 223 199 46 30 37 57 175 203 186 142 86

%

93% 96% 90%

All

medical

units

207 187 210 209 54 43 63 72 153 144 147 137 78

%

90% 87% 92%

All major

ICUs

44 42 51 48 11 6 9 13 33 36 42 35 94

%

94% 98% 91%

All acute

care units

472 462 484 456 111 79 109 142 361 383 375 314 301 (83%)

351 (92%)

347 (93%)

286 (91%)

Appropriate* Prophylaxis by Unit Groups

*defined as consistent with Sunnybrook policy

Limitations of auditing adherence

Usually limited in scope (single unit/service)

Usually 1-time snapshots of care

Usually don’t audit “optimal” prophylaxis but rather

“any” or “on the list” prophylaxis

If local policy is not optimal, good adherence may not

improved outcomes

Surrogate for clinically-important outcomes

Often targets the wrong audience e.g. RNs,

pharmacists rather than the order writers

Questionable impact on providers

Assessing the success of

VTE prevention programs

Essential to measure the impact of patient

safety/QI efforts

Two types of outcomes:

1. Process measures - % of patients at risk

for VTE who receive appropriate

thromboprophylaxis

2. Clinical measures – DVT, PE,

complications

Methodology of clinical outcome audits

1. Retrospective health records data

2. Real time prospective case finding

3. Real time case finding + feedback

2 types of real-time HA-VTE audits

1. All events (research study)

- very time consuming

2. Representative events (QI initiative)

1

2

Limitations of auditing clinical outcomes

(VTE)

Difficult to find all cases of HA-VTE

Resource intensive to find cases, review

details, do root cause analysis

Many HA-VTE occur after discharge

Relatively small numbers per unit - may

be “underwhelmed” by results

Sunnybrook’s approach

1. Retrospective health records data

2. Real time prospective case finding

3. Real time case finding + feedback

Let’s try to find as many symptomatic, proven HA-VTE

cases as we can

Try to find them ASAP after the diagnosis

Do a root cause analysis on these cases

All the identified cases of HA-VTE go into a database

Provide timely feedback to the care team if

thromboprophylaxis wasn’t optimal

3. Using RCA in VTE prevention

quality improvement

Val Valenzuela, RN

Thrombosis nurse, Sunnybrook HSC

Artemis Diamantouros, BScPhm, PhD

Knowledge Translation pharmacist, Sunnybrook HSC; National Coordinator VTE Prevention, Safer Healthcare Now!

VTE QI in real time

Methods

Case finding: Medical Imaging list of positive leg Dopplers

+ daily Thromboembolism Service

Cases: symptomatic, confirmed DVT or PE >2 days after

admission and <2 months after discharge

Standardized root cause analysis of causative and

contributing factors for the event

Did the patient receive appropriate thromboprophylaxis as

per Sunnybrook policy?

1. Potentially preventable VTE: written feedback to

the patient’s care team

2. “Unpreventable VTE”: enter into HA-VTE database

Symptomatic Hospital-Acquired DVT/PE (>2 days after adm to 2 months after discharge)

Appropriate* thromboprophylaxis

Suboptimal* thromboprophylaxis

(=potentially preventable)

Root cause analysis (causative/contributing factors)

Provide feedback to the care team

Enter into database

Review our VTE Policy & Guidelines

*according to Sunnybrook’s Thromboprophylaxis Policy and Guidelines

Excl: upr extrem, abd, CNS, incidental

Hospital-Acquired DVT/PE 2011-14 (n= 198; 4.7/month)

Appropriate* thromboprophylaxis

(133 = 67%)

Suboptimal* thromboprophylaxis

(=potentially preventable)

(65 = 33%)

Root cause analysis

Provide feedback to the care team

Enter into database

Review our VTE P&G

1.5/mo

*according to Sunnybrook’s Thromboprophylaxis Policy and Guidelines

0

5

10

15

20

25

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

U-VTE

P-VTE

Hospital-Acquired VTE by Month

(2011-14)

Total/month:

15 12 13 10 12 14 20 29 26 16 18 13

0

5

10

15

20

25

30

Hospital-Acquired VTE by Nursing Unit

(2011-14)

Total/nursing unit:

3 1 2 4 14 1 5 18 38 23 2 2 3 0 2 3 21 33 5 1 1 5 3 6 0 2

0

5

10

15

20

25

30

35

Series1

Series2

Hospital-Acquired VTE by Clinical Service

(2011-14)

U-VTE

P-VTE

Total/clinical service:

3 1 0 0 18 48 16 1 17 1 0 24 0 0 28 2 3 5 1 1 0 22 7 0

GynOnc GenSur NS Ortho Traum MedOnc CarSur GIM Cardio 2011-13

1.6%

1.4%

1.2%

1.0%

0.8%

0.6%

0.4%

0.2%

0

Adm 1,036 3,148 1,536 1,757 2,066 2,852 1,285 8,761 2,591 31,106

HA-

VTE 14 37 15 13 15 14 2 10 0 137

1.35% 1.18% 0.98% 0.74% 0.73% 0.49% 0.16% 0.11% 0 0.44%

Hospital-Acquired VTE by Clinical Service

(2011-13)

Services with >1000 admissions

Potentially Preventable HA-VTE

65 potentially preventable HA-VTE, July 2011 – Dec 2014

22 (34%)

18 (28%)

15 (23%)

4 (6%)

3 (5%)

2 (3%)

4 (6%)

34%

28%

23%

6% 5% 3% 2%

Incorrect dose

Inappropriate delay

No prophylaxis given

TEDs use suboptimal

Inadequate duration

SuboptimalcomplianceOther

Limitations of this type of HA-VTE audit

Underestimates true HA-VTE rates

- OK = we’re not trying to find all events

Time consuming to find as many cases as is

“reasonable”

- 30-60 minutes/week

Benefits of this type of HA-VTE audit

Identifies clinically-relevant outcomes (“real

patients harmed”)

Provides insights not seen with other audit

methods

Real-time feedback (the care team will

know/remember the patient)

Complements audits of adherence

Can inform changes in policies and guidelines

Mrs. Jones.

Take Home Messages

Root cause analysis is a powerful quality

improvement tool

- Individual incident

- Multi-incident

RCA can be used in VTE prevention QI

Provides unique insights into care and can be

used to help change culture

Keep up the great work – clots can be beaten!

“Taking the Pulse” Poll / Sondage

Instructions to download certificate

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2 3

4

5

8

9

Thank you!

Questions; comments/suggestions

How can Safer Healthcare Now!

help you?

Artemis Diamantouros 416-480-6100 x 3654

Email: [email protected]

Bill Geerts

Email: [email protected]