Quality Reporting in the Cardiothoracic ICU Quality Improvement Project June 6, 2016 Justin Schulte, MD, Leah Webb, MD, Peter Ritchie, MD Breandan Sullivan, MD, Thomas Notides, MD

Medical Error Medical errors are common and have serious consequences 1999 IOM report estimated 44,000-98,000 deaths annually in the US as a result of medical error (1) 2016 analysis estimate even higher – 251,000 deaths annually in the US from medical error (2) 3rd leading cause of death behind heart disease & cancer Morbidity, mortality, cost Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. National Academies Press. 1999. Makary M, Daniel M. Medical error – the third leading cause of death in the US. British Medical Journal. 2016.

Tracking Errors UCH uses a system called Safety Intelligence for reporting and tracking adverse events, near misses, and staff concerns regarding quality and safety Utilization of this system, specifically in the CTICU, is quite low Just 2 reports filed over a 6 mo. period in 2015

Why Underreporting? 32 anesthesiology resident polled 62% familiar with the hospital reporting system 3% knew the name of the system 16% had used the system to file a report Barriers to reporting Poor education on what/how to report Report is time consuming to access and complete Fear of repercussion from reporting errors Perceived lack of change resulting from reporting

Improving Reporting New, simplified, easy to use, readily available, less burdensome

CTICU Safety Card New card designed for QI reporting in CTICU Staff educated on new reporting option Cards readily available throughout the CTICU System established for collection and review of submitted cards Requires participation of many departments involved in caring for CTICU patients Institute change to address reported issues

Result First 2 months of the new system 12 cards submitted improvement over old system

Room for Improvement Our new system resulted in increased reporting However, majority of events still go unreported Need increased attention to review process This is what ultimately institutes change Need improved feedback to our reporters to encourage future reporting and foster culture of safety and quality improvement

References 1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. National Academies Press. 1999. 2. Makary M, Daniel M. Medical error – the third leading cause of death in the US.  British Medical Journal. 2016. 3. Donchin Y, Gopher D, Olin M, et al.  A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995.

Thanks to Dr. Donnelly QI Team Dr. Sullivan & Dr. Notides CTICU Staff