HIT Policy Committee Patient Safety Tiger Team Summary Neil Calman Institute for Family Health October 28, 2010

Neil Calman, Chairperson Peter Basch Tripp Bradd Russ Branzell Peter Briss Marc Overhage Jacob Reider 2 Patient Safety Tiger Team Members

Maximize impact: Select measures that have a large impact on patient safety in both hospitals and ambulatory settings HIT sensitive: Selecting measures that are affected by HIT Be parsimonious: Identify measures where performance on targeted set of metrics is likely to have a large beneficial corollary effects on how care is delivered for other outcomes and patients Focus on reporting: Selecting measures that are reportable to monitor improvement and focus on outcomes 3 Four Guiding Principals for our Team

1.Medication Safety—Measures pertaining to the prevention and reporting of Adverse Drug Events (ADEs) and use of evidence-based medicine. 2.Hospital Associated Events—Measures related to the prevention and reporting of HAIs, VTEs, and Falls. 3.Patient Identification—Measures focused on improving patient safety by positively identifying patients. 4.EHR Errors—Measures that establish a mechanism to report EHR related errors to improve EHR functionality and maximize patient safety in the context of EHR use. 4 We have Identified Four Patient Safety Sub-Domains

Measure Concept Recommendation 1. Medication Safety Measure of reported adverse drug events through the FDA Adverse Event Reporting System (AERS) database Recommendation for a mechanism for automatic submission of the report through EHRs Measure to assess medication error prevention 5

Measure Concept Recommendation 2. Hospital Associated Events Measures of process and outcome improvement of hospital associated infections (HAIs) Measures of venous thromboembolism (VTE) prophylaxis and incidence Measures of falls events and screening 6

Measure Concept Recommendation 3. Patient Identification Measure of patient identification errors Recommendation for EHR functionality to facilitate correct patient identification 7

Measure Concept Recommendation 4. EHR Errors Measure of common EHR related errors such as those that lead to delays in care or missed results. 8

Patient Safety Questions? 9

10 PULL IN THE BLUE BOX FROM THE SUMMARY TABLE WITH THE UNIVERSE OF MEASURE CONCEPTS  Documentation and reporting adverse drug events.  Bedside medication verification.  Use of clinical decision support (CDS) for high-risk medications and medication orders.  Correct medication reconciliation for Eligible Providers s as well as hospitals.  Reporting of hospital acquired infections (HAI), venous thromboembolic events (VTE), and falls.  Use of CDS to reduce HAIs, falls, and provide prophylaxis for VTE patients.  Measurement of provider compliance with reducing HAIs, falls, and VTEs after an alert has been issued.  Monitoring of pressure ulcers.  Conduct of bedside medication verification.  Prevention of patient identification errors.  Review of the number of reports missed in an EHR.  Reporting of incorrect or inappropriate clinical suggestion from an EHR.  Reporting delay of care caused by errors related to EHR use.  Warfarin monitoring.  Reporting of the percentage of high- risk medications given to the elderly.  Reporting of never events as defined by the National Quality Forum (NQF).  Prevention pressure ulcers. APPENDIX: Summary of Patient Safety Measure Concepts