ABSTRACT
After extensive review of the literature and analysis of the six dimensions
of quality (safety, effectiveness, efficiency, timeliness, patient-centeredness,
and equity) in the Institute of Medicine report, "Crossing the Quality
Chasm", we conducted sentinel event analysis using medical/clinical errors
data for 78,364 hospitals and nursing homes. In particular, we analyzed
independent predictors of re-hospitalization, procedure complications,
wrong-site surgery, treatment delay and restraint death. Risk factors used
included blood type mismatch ("A" and "O"), mis-spelling of names, control
of medications (storage/access, labeling of medications), supervision of
staff, adequacy of technological support, staffing levels, patient identification
process, patient observation procedures, care planning process credentialing,
orientation and training of staff, competency assessment, physical environment,
communication among staff members, physical assessment process, behavioral
assessment process, communication with patient/family.
We also included the provider related information to explain the outcome
variables, viz: (i) board certification
of physician---an indication that the latter is highly trained, competent
and experienced, (ii) accreditation of health plan physician credentials
by the National Committee for Quality Assurance (NCQA), (iii) patient satisfaction
and utilization review, (iv) performance report cards of independent quality
assurance organizations --- a measure the effectiveness of the HMO's doctors
in preventing disease or detecting it early.
We classified each of hazardous conditions into one of 5 groups: human,
communication, environmental, supplies / equipment, and policies / procedures
and used Monte Carlo simulation technique to analyze which group contributed
more to a specific sentinel event.
The results of the root cause analysis were used by policymakers to improve
the process of care in participating hospitals and SNFs. Policy makers
to established a national medical errors database in order to track and
trend the errors of providers, initiate mechanisms to prevent a recurrence
of the sentinel event or to reduce the risk of a future close call. From
the policy recommendations, Patient Safety Journal, PSJ, was developed
to disseminate timely and practical information to reduce medical error.
Some of the items found in PSJ have reduced medication-ordering errors,
re-hospitalization rates and decreased bedsores and falls.
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