New York State Department of Health - NYPORTS
Analysis of Selected NYPORTS Codes
In support of its primary focus-improvement of patient care and safety-NYPORTS continues to accumulate and disclose a wealth of corrective actions and risk reduction strategies, stemming from the tracking, trending, and sharing of serious occurrences requiring Root Cause Analysis. Risk reduction strategies from each NYPORTS occurrence code will be shared as analysis is completed. This important information is being used by facilities to modify their current systems to enhance patient safety and ensure desired outcomes.
The first in-depth analysis of root cause findings and corrective actions for code 912 (Incorrect treatment or procedure, invasive) has been completed. This information has been shared with facilities through the "NYPORTS News and Alert" and by the Department providing copies of the analysis to individual facilities.
The analysis supports the development by facilities of pre-procedure protocols to include invasive procedures done in areas outside the operative suite, such as the bedside, radiology, emergency department, or other specialty areas.
The results of the analysis of NYPORTS code 912 (Incorrect Procedure or Treatment, invasive) are located in Appendix C. This appendix is an excerpt from the full analysis of code 912, which consists of 80 adverse occurrences within the time frame of June 2000 to August 2001.
Appendix C yields three specific areas of identified adverse event categories, both inside and outside the surgical suite. These categories became apparent after analyzing the data in aggregate form. The number column of the table reflects the frequency of occurrence of each particular category. Root causes have been identified from scrutiny of hospital-submitted Root Cause Analysis. Risk Reduction Strategies have been developed from both hospital identified solutions and commonly accepted standards of practice. The root causes identified, as well as the risk reduction strategies, are given and correlate by number (i.e., Risk Reduction Strategy #1 was identified as a method to reduce or eliminate the occurrence of Root Cause #1). The root causes and risk reduction strategies appearing in boldface type were the result of the statewide analysis of aggregate data, and those appearing in normal type were identified by the hospitals as part of their RCA process.
In 2002, the Department assembled a Data Analysis Panel, consisting of a multidisciplinary team of experts including physicians, a pharmacist, and registered nurses to review Code 915 (Unexpected death not directly related to the natural course of illness or underlying condition) events. The panel members reviewed occurrences that were submitted from June 1, 2000 to December 31, 2001. These occurrences have been divided into seven categories: Medication-related, Neurological, Cardiac, Pulmonary, Maternal, Neonatal, and Surgical/Procedural. The preliminary results of the Pulmonary and Pharmacological-related analysis are available in Appendix D. The Department's goal is to extract root causes and risk reduction strategies identified by individual hospitals in their own RCAs, as well as common themes that became apparent only when the data were examined on a statewide level. The panel has added risk reduction strategies based upon standards of medical practice and evidence-based medicine. The goal of the data analysis is to share the identified risk reduction strategies so that every facility in New York State may have the benefit of this information to improve patient safety.
NYPORTS News and Alert
The Department of Health distributes a newsletter, the "NYPORTS News and Alert", on a quarterly basis to all hospitals in New York State. The "News and Alert" is sent to Hospital Administration and the NYPORTS Coordinator designated by the hospital. This newsletter is designed to give system users information to assist with the reporting process. Additionally, it has been used to publish results of analysis, including root causes and corrective actions.
Historically, the distribution of the "News and Alert" has been a paper process. In 2001, the Department has instituted electronic distribution of this newsletter, in addition to paper distribution.
The following is an example of a "News and Alert" article that was published in the September 2002 issue.
Retained Surgical Sponges
The retained surgical sponge/lap pad occurrence is less likely to garner public notoriety typical of a wrong site surgery. However, a NYPORTS analysis completed in 1999 (News and Alert #3) and updated in July, 2001 (News And Alert #9) found that surgical sponges and lap pads are the most frequently retained foreign objects after the surgical procedure. Retained sponges/lap pads can result in serious conditions including sepsis, intestinal obstruction, fistula or abscess formation and adhesions. A secondary surgical procedure is often required for removal of the retained foreign item.
The NYPORTS findings have prompted an interest in retrospective analysis of the Root Cause Analysis (RCA's) submitted for code 913 (Unintentionally retained foreign body due to inaccurate surgical count or break in surgical technique). The purpose of the analysis is to identify methods and suggestions presented in the RCA's that might improve the accuracy of the surgical count and decrease the occurrence of a retained surgical sponge or lap pad.
Many corrective actions from RCA's suggest utilization of x-ray to identify retained foreign bodies. The use of sponges containing a radiopaque marker substantially improves the ability to locate them in a x-ray. While this is a widely used practice, it does not prevent the retention of surgical sponges. Although the use of x-ray is a standard diagnostic tool in locating a retained sponge or lap pad, there can be great variability in their appearance, leading to diagnostic misinterpretations. It may be helpful for facilities to maintain a collection of examples of the x-ray appearance of retained surgical sponges to assist the Radiologists/Surgeons with identification.
The Association of Operative Registered Nurses (AORN Journal Dec 1999) recommends that sponges be counted:
- Before the procedure to establish a baseline,
- Before closure of a cavity within a cavity,
- Before wound closure begins,
- At skin closure or end of procedure, and
- At the time of permanent relief of either the scrub person or the circulating nurse.
Also, sponges should be counted and recorded when added to the field.
RCA's note that even with this meticulous care, inaccurate counts can occur when surgical sponges stick together or when situations interrupt the counting process (common root causes). Additional suggestions compiled from NYPORTS RCA's include:
- Using two individuals to perform the surgical count, instead of one.
- Consulting the attending radiologist to determine which radiographic pictures would be most beneficial in locating a retained sponge or lap pad.
- Developing protocols for extended situations that may warrant x-ray examination in addition to surgical counts, such as when surgical sponge count is impacted by emergent situations.
- Considering a protocol to account for the use of an unusual or different type of sponge/lap pad, other than what was planned for procedure.
This example illustrates the importance of information obtained from analysis of NYPORTS data. This issue of "NYPORTS News and Alert" is available to view at the end of this report.
Agency for Healthcare Research and Quality Patient Safety Grant
The Department has been awarded a three year federal grant totaling $5.4 million from the Agency for Healthcare Research and Quality (AHRQ) to support its ongoing efforts to improve patient safety. The goals of the New York State Safety Improvement Demonstration Project are to improve the completeness of reporting in NYPORTS, to identify the causes of preventable errors and patient injury in health care using the root cause analysis process, and to develop, demonstrate and evaluate strategies for reducing adverse events and improving patient safety through hospital interventions. The goals will be accomplished through two initiatives: assuring more complete reporting in NYPORTS so that more meaningful analysis of data can occur and overseeing three demonstration projects involving hospital groups or networks that will study specific types of adverse outcomes and will develop and test interventions to reduce their occurrence.
The goal of improving NYPORTS reporting has been accomplished in several ways. Interviews were conducted for a sample of hospitals across New York State to determine the key characteristics of an effective concurrent detection system. A survey will be developed and sent to all hospitals to determine whether those hospitals having these key characteristics do in fact have an effective concurrent NYPORTS reporting process. Additionally, linking NYPORTS and SPARCS to identify potential missed events has proven effective in improving reporting. Training medical record coders about NYPORTS is another initiative being carried out to improve the quality of the SPARCS database and also identify potential NYPORTS cases. Having more effective systems will lead to better quality data, which in turn will lead to improved patient safety practices.
In fulfilling the second initiative, awards were made to three hospital groups in June, 2002 totaling $1.7 million, to reduce the occurrence of three common and preventable occurrences reported in NYPORTS. The projects are funded through August 14, 2004. Summaries of the three projects are as follows:
The Westchester Medical Center group (Westchester Medical Center, Westchester Medical Center White Plains Pavilion, Benedictine Hospital, Kingston Hospital and Ellenville Regional Hospital) analyzed current use of antimicrobials and found that antibiotics that are considered broad spectrum and should be reserved for treatment of infections were being used for surgical prophylaxis and then continued to be administered after the surgery was completed. This is contrary to published recommendations and can lead to increased antibiotic resistance and significantly increased costs to the facilities. In addition, antibiotics were not administered at the optimum time before surgery to achieve optimal serum and tissue levels.
As a result, standardized surgical antimicrobial prophylaxis protocols for the administration of antimicrobial prophylaxis (AMP) were developed using evidenced based medical literature. The protocols are designed to standardize the use of prophylactic antimicrobial agents in association with select clean and clean-contaminated surgical procedures. The development of these protocols involved active participation from the surgical staff and the anesthesia departments. These protocols were approved by the appropriate surgical related committees in each of the participating hospitals. A consensus statement was developed indicating that compliance with these protocols is consistent with the standard of practice in each of the participating hospitals. Compliance with these protocols will be monitored through the study period. The intervention was implemented on January 1, 2003 and data collection for the analysis of the intervention was initiated on February 1, 2003. The demonstration project will be completed on August 15, 2004 and the results will be disseminated throughout NYS.
The Rochester Regional Thromboembolism Collaborative (Strong Memorial Hospital, Highland Hospital, F.F. Thompson Hospital, St. James Mercy Hospital and Jones Memorial Hospital) has developed the risk assessment and prophylaxis protocols based on evidenced based medicine via collaborative multidisciplinary committee work. The protocols were piloted at all five hospitals and revised based on the piloting. The Data Collection Tools and corresponding Data Dictionary were developed to be utilized for a sample of cases in the 2001 baseline period and the study period to assess compliance with the risk assessment and proper use of thromboembolic prophylaxis. The risk assessment tool and prophylaxis intervention was implemented across the study hospitals in April 2003.
The School of Public Health in Albany, as part of a qualitative analysis project, conducted site visits at all participating hospitals in November 2002. Individuals at all levels were interviewed; physicians, registered nurses, nurse practitioners, etc and preliminary feedback was provided via conference call in February 2003.
A web site was developed for the DVT/PE NYPORTS project. Information regarding the project is now at the fingertips of all participants and gives them the ability to stay informed up to the minute through the distribution of materials through the web site.
The New York Presbyterian-Healthcare System project (New York Presbyterian Hospital-Columbia, New York Methodist, New York Medical Center Queens, St. Barnabas and White Plains Hospital Center) is completing the development of the 2001 baseline of perioperative MI cases meeting study criteria by electronically matching surgical DRG codes matched with a laboratory database of elevated enzymes. Medical Directors have reviewed all AMI cases and a 10% sample of ineligible cases.
The Medical Directors Committee of the New York Presbyterian Healthcare System adopted a system wide evidence-based consensus statement recommending the use of perioperative B-blocker therapy in appropriately selected patients undergoing non-cardiac surgical procedures. This statement includes perioperative risk stratification and guidelines for the appropriate use of B-blocker prophylaxis. Current data indicates an underutilization of perioperative B-blockers within the system. A multi-dimensional educational intervention was implemented in January, 2003 aimed at changing clinician behavior and improving the clinical utilization and effectiveness of B-blocker therapy. Modalities include multidisciplinary grand rounds and divisional lectures, improved coordination of care among preoperative medical staff, utilizing a web-based education program, providing supportive materials (i.e.- posters, pocket cards) and support of local opinion leaders. Compliance to these protocols will be measured throughout the study period.
The intervention began on April 1, 2003. All research personnel have been trained to work on the project. Communication among all participants is important and is enhanced by a secured program web site. Weekly telephone conferences occur among all Medical Directors and key project personnel.
NYPORTS Information Prompts Hospital Studies
NYPORTS reporting and the resultant access to comparative data have prompted individual facilities to conduct their own system studies. Using the information gained through the NYPORTS system, facilities can target areas of concern and perform focus studies. The results of these studies have been significant in improving patient care and safety, as well as reducing hospital costs.
As a direct result of NYPORTS initiatives, the Department has created the "New York State Hospital Patient Safety Award" program. This award recognizes 2 hospitals based upon their accomplishments in promoting patient safety and reducing medical errors. Each hospital will receive the award and a grant of up to $ 200,000 to work with the Department in promoting their patient safety strategies for other hospitals and care providers in New York State.
The recipients of the First Annual New York State Hospital Patient Safety Awards were announced at a conference, jointly sponsored by the Agency of Healthcare Research and Quality (AHRQ) and the Department of Health, "Working Together: How Hospitals Can Ensure Patient Safety" in January of 2002. The recipient of the award for hospitals with over 200 beds was Ellis Hospital, Schenectady, and the winner for hospitals under 200 beds was The Hospital for Special Surgery, Manhattan.
Ellis Hospital was recognized for its efforts to reduce the risk of dangerous clots forming in hospitalized patients. A comprehensive risk factor assessment and treatment protocol was established to identify and treat patients at risk for this complication. This assessment is now part of the hospital's admission process and is recorded in each patient's chart and care plan during their hospital stay. Since instituting this new screening process, there has been a significant decrease in the number of hospital-acquired deep vein thrombosis (blood clots) and pulmonary embolus.
The Hospital for Special Surgery was recognized by the Department for its innovative program leading to improvement in the medication use process. This initiative established hospital protocols to ensure legibility of medication orders, which resulted in a 97.6% decline in the number of illegible orders from November 2000 to December 2001. This short term error reduction strategy focused on the 'process of process improvement', helping to meet the Hospital's short-term goal of enhancing current systems and processes, while working towards the long term goal of Computerized Physician Order Entry (CPOE).
In addition to the award-winning hospitals, seven other New York hospitals received Honorable Mention awards and were recognized for their work to establish patient safety programs, including:
- Albany Medical Center, Albany- Developed a comprehensive automated data collection system to identify, monitor and track the distribution of medications to patients. The database helps pharmacists cross check the possibility of adverse reaction in patients prescribed multiple drugs at once;
- Mercy Medical Center, Rockville Center- Enhanced policies to prevent medication errors from occurring, including the development of a universal flow chart to track drug distribution to patients;
- New York Presbyterian Hospital, New York City- Strengthened policies related to the assessment of patients admitted to the emergency department for acute myocardial infarction (heart attack);
- North Shore University Hospital, Forest Hills- Enhanced protocols for administering antibiotics to prevent infection in patients immediately following surgical procedures;
- Park Ridge Hospital, Rochester- Strengthened policies related to the tracking and dispensing of medications to patients to prevent errors from occurring, implemented interventions for reducing the incidence of central line related blood stream infections in ICU patients, and improved patient safety related to safety hazards due to wheelchairs in disrepair;
- The Hospital for Joint Diseases, New York City- Developed comprehensive policies to identify the correct area of surgery on patients to help prevent wrong-site surgeries from occurring; and
- Wyckoff Medical Center, Brooklyn- Strengthened policies related to identification and prevention of medication errors that may result from relying on written orders.
The Second Annual Patient Safety Awards were expanded to not only to acknowledge the effort of hospitals in improving patient safety, but also to recognize the efforts of nursing homes and Federally Qualified Health Care Centers (FQHC). The 2002 Patient Safety Award recipients are Children's Hospital, Buffalo (hospitals over 200 beds), and Albany Memorial Hospital, Albany (hospitals under 200 beds). The Nursing Home award recipient is United Health Services. Ideal Senior LivingCenter, Endicott, and the FQHC award recipient is Sunset Park Family Healthcare Center Network of Lutheran Medical Center, Brooklyn.
Children's Hospital, Buffalo, was acknowledged for their efforts to improve and ultimately, eliminate errors of medication prescription. The program was implemented in 1998, with a review of 21,000 medical records, which identified specific focus areas. In response to this exercise, the facility developed order forms that promote improved completeness and accuracy through a forced function format. In addition, the program included a plan to reduce the frequency of incorrect orders. Personal digital assistants (PDA) were given to house staff to assist in this effort. The facility noted a 48% reduction in incorrect drug selection, dose and frequency during a one year observation period. Children's Hospital has also developed a website tutorial and competency exam for medication prescription. This website tutorial is a requirement for all new residents to the facility.
Albany Memorial Hospital, Albany, has been recognized for their efforts in coordinating care management for patients with heart failure. This program utilizes a professional nurse case manager to facilitate care for patients with complex medication regimens and high risk for hospitalization across the continuum of care. This effort includes successful strategies for an integrated information system, a full spectrum of services from primary care through long term care, dedicated resources and system wide commitment to this program, seamless transition across the continuum, and empowerment of patients with self care management. The result of this program has been a 75% reduction in hospitalizations and a 100% reduction in Emergency Department visits for patients utilizing this program.
United Health Services-Ideal Senior Living Center, Endicott, received the Patient Safety Award for efforts in developing a prevalence study of residents with pressure ulcers. The program was initiated in April 2000 and the prevalence rate was found to be at 22%. An interdisciplinary team was structured and all residents were re evaluated. It was determined that all residents would continue to be reassessed quarterly and annually, with episodic charting of skin integrity changes, lab chemistry changes, and weight changes. Any residents with status changes would be discussed at morning report and immediate follow-up would occur. This effort to reduce pressure ulcers resulted in a rate decrease from 22% in June 2000 to 9% in June of 2001, and to 5% in June of 2002.
Sunset Park Family Healthcare Center Network of Lutheran Medical Center, Brooklyn, has been instrumental in providing services to under served neighborhoods of southwest and central Brooklyn since 1967. Their Patient Safety proposal included a number of improvement areas such as patient satisfaction, expedited HIV testing, management of pediatric asthma patients and testing in adult diabetics. Significant improvements were demonstrated in these categories as a result of quality improvement interventions. For example, prior to the implementation of the Diabetes Management Program, 80% of adult diabetics had evidence of an annual test in 1999. This percentage has increased to 95% in 2002 through several effective interventions, such as the creation of a diabetic registry, the use of an interdisciplinary team approach to care, the development of clinical guidelines, the use of a self management education program for adults, and the use of case management services for high risk patients. In addition, Sunset Park instituted a program of pre registering and tracking of all prenatal patients to ensure that expedited testing was not needed at the time of delivery. The program reduced the rate of expedited testing at birth from 44% in 2001 to 3% in March 2002.