1. Center for Patient Safety Research and Practice David Bates, MD, MSc Center Director

2. Overview Background Background Accomplishments to date Accomplishments to date  Before the Center  Of the Center itself  Other related Future vision Future vision

3. Safety and Systems “Every system is perfectly designed to achieve exactly the results it gets.” Donald Berwick “Safety is a systems property.” Chasm Report

6. National Developments CMS announced plan 4/14 to stop paying for Serious Reportable Adverse Events (“never” events)—n=28 CMS announced plan 4/14 to stop paying for Serious Reportable Adverse Events (“never” events)—n=28 FDA has announced plans to develop “Sentinel Network” FDA has announced plans to develop “Sentinel Network” Agency for Healthcare Research and Quality devoting few resources to safety research (main recent focus HIT) Agency for Healthcare Research and Quality devoting few resources to safety research (main recent focus HIT)

7. BWH As A Leader: Inpatient Prevention—Computerized Physician Order Entry 55% reduction in serious medication error rate with CPOE 55% reduction in serious medication error rate with CPOE Bates, JAMA, 1998 83% reduction in overall medication error rate 83% reduction in overall medication error rate Bates, JAMIA, 2000

8. NEPHROS study Effect of real-time decision support for patients with renal insufficiency Of 17,828 patients, 42% had some degree of renal insufficiency Of 17,828 patients, 42% had some degree of renal insufficiency Interv Control Interv Control Dose67%54% Frequency59%35% Length of stay 0.5 days shorter Length of stay 0.5 days shorter Chertow et al, JAMA 2001

9. Medication Systems Then and Now

10. THEN

12. NOW

13. Slide Courtesy of Anne Bane, RN, MSN. Brigham and Women’s Hospital BCMA

15. Medication Location

16. Slide Courtesy of Anne Bane, RN, MSN, Brigham and Women’s Hospital

17. Dispensing Errors and Potential ADEs: Before and After Barcode Technology Implementation Projections for errors prevented per year at study hospital: >13,500 medication dispensing errors >13,500 medication dispensing errors >6,000 potential ADEs >6,000 potential ADEs 31% reduction* 63% reduction* * p<0.0001 (Chi-squared test) Poon, Ann Intern Med, 2006

18. Formal Cost Benefit Analysis Results 5-year cumulative costs = $2.3M 5-year cumulative costs = $2.3M  $1.4M one-time investment (pre go- live, first 2 years)  $343K/yr recurring (post go-live, last 3 years) 5-year cumulative benefits = $5.5M 5-year cumulative benefits = $5.5M 5-year cumulative net benefit = $3.3M 5-year cumulative net benefit = $3.3M Break-even within 1 st year after go-live Break-even within 1 st year after go-live Maviglia, Arch Int Med 2007

19. Improving the Response to Critical Labs Baseline revealed that a third not treated for 5 hours Baseline revealed that a third not treated for 5 hours Mean time to treatment11% shorter Mean time to treatment11% shorter Mean time to resolution 29% shorter Mean time to resolution 29% shorter Mortality was 7% in intervention group, 13% control group (p=0.19) Mortality was 7% in intervention group, 13% control group (p=0.19) 95% physicians pleased to be paged 95% physicians pleased to be paged Kuperman, JAMIA 2000

20. Coverage-Related Events Before data showed patients being cross- covered at 5-fold excess risk of adverse event Before data showed patients being cross- covered at 5-fold excess risk of adverse event After computerized signout introduction, no excess risk After computerized signout introduction, no excess risk  Included medications Simple from informatics perspective but major benefit Simple from informatics perspective but major benefit Petersen, Jt Comm Jl

21. Take-Away Messages of Smart Pump Controlled Trial Serious IV med errors were frequent and could be detected using smart pumps Serious IV med errors were frequent and could be detected using smart pumps However, no impact on the serious med error or preventable ADE rate was found However, no impact on the serious med error or preventable ADE rate was found  Likely because of poor design and also compliance Behavioral and technologic factors must be addressed if smart pumps are to achieve their potential for improving medication safety Behavioral and technologic factors must be addressed if smart pumps are to achieve their potential for improving medication safety Rothschild et al, Crit Care Med 2005

22. Reporting and Surveillance Tool Safe Intravenous Infusion Systems Inpatient Psychiatric Epidemiology Study Ambulatory Pediatric Epidemiology Study Improving Safety in Nursing Homes Organizational culture in promoting patient safety

23. Dissemination Efforts (I) Newsletter Newsletter Website: www.coesafety.bwh.harvard.edu Website: www.coesafety.bwh.harvard.eduwww.coesafety.bwh.harvard.edu Presentation of findings at national meetings Presentation of findings at national meetings  SGIM, AMIA, NPSF, NICHQ, SCCM, Annual AHRQ Patient Safety Conference Harvard CME Course on Patient Safety Harvard CME Course on Patient Safety ITV Patient Safety Special ITV Patient Safety Special

24. Dissemination Efforts (II) AHRQ Webcast AHRQ Webcast Dr. Bates, Gurwitz served on recent IOM Committee Dr. Bates, Gurwitz served on recent IOM Committee WHO WHO  Dr. Leape led drafting of WHO Guidelines for Adverse Event Reporting and Learning systems  Dr. Bates leading development of global agenda for patient safety research

25. HIT-CERT Studies Automated telephone surveillance in outpatients prescribed specific medications to determine whether or not they are experiencing specific ADEs Automated telephone surveillance in outpatients prescribed specific medications to determine whether or not they are experiencing specific ADEs Evaluation of the impact of clinical decision support and automated telephone outreach on antihypertensive and lipid-lowering therapy Evaluation of the impact of clinical decision support and automated telephone outreach on antihypertensive and lipid-lowering therapy Characterization of new errors with ambulatory electronic prescribing Characterization of new errors with ambulatory electronic prescribing Post-discharge ambulatory medication reconciliation Post-discharge ambulatory medication reconciliation Evaluation of multiple vendor-based electronic prescribing systems and health information exchange on outpatient medication safety in Mass and New York Evaluation of multiple vendor-based electronic prescribing systems and health information exchange on outpatient medication safety in Mass and New York Identification with AMIA of a set of clinical decision support rules that can be used in multiple settings Identification with AMIA of a set of clinical decision support rules that can be used in multiple settings

26. Other Grants Study beginning supported by Pfizer to study automation of ambulatory adverse drug event reporting Study beginning supported by Pfizer to study automation of ambulatory adverse drug event reporting Study of safety climate in nursing homes underway Study of safety climate in nursing homes underway Closing the loop on missed and delayed diagnoses Closing the loop on missed and delayed diagnoses Support to study role of pharmacists in the ED Support to study role of pharmacists in the ED Study of the impact on safety of a chemotherapy robot Study of the impact on safety of a chemotherapy robot Study of impact of attending fatigue on error rates Study of impact of attending fatigue on error rates Study funded by Aetna looking at personalizing breast cancer care based on genomic data Study funded by Aetna looking at personalizing breast cancer care based on genomic data Funding from WHO to assess global burden of patient safety Funding from WHO to assess global burden of patient safety

27. Massachusetts eHealth Collaborative Effort to get all providers in state to use electronic records Effort to get all providers in state to use electronic records Have given EHRs and set up clinical data exchange in 3 communities Have given EHRs and set up clinical data exchange in 3 communities Evaluating impact on quality, safety, and efficiency Evaluating impact on quality, safety, and efficiency A potential model for rest of U.S. A potential model for rest of U.S.

28. Areas of Particular Interest Medication safety Medication safety Surgical safety Surgical safety Nosocomial infections Nosocomial infections Improving monitoring Improving monitoring  Of patients  Of devices Diagnostic error Diagnostic error Using technology effectively Using technology effectively Safety culture/organizational interests Safety culture/organizational interests

29. Vision for Center BWH has long been leader in this area BWH has long been leader in this area Multi-institutional, multi-disciplinary program Multi-institutional, multi-disciplinary program  Goal to bring together the best in this area  Provide core support, foster collaboration  Already have many investigators working in parallel Longitudinal focus is essential—problem is not going to go away Longitudinal focus is essential—problem is not going to go away