A Decade of Preventing Harm.

Unlabelled: Medical errors are a significant source of morbidity and mortality, and while focused efforts to prevent harm have been made, sustaining reductions across multiple categories of patient harm remains a challenge. In 2008 BJC HealthCare initiated a systemwide program to eliminate all major causes of preventable harm and mortality over a five-year period with a goal of sustaining these reductions over the subsequent five years.

Methods: Areas of focus included pressure ulcers, adverse drug events, falls with injury, health care-associated infections, and venous thromboembolism.

Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

Purpose: Substantial reductions in inpatient episodes of severe hypoglycemia achieved by a large healthcare system through enhanced use of technology and sustained quality-improvement initiatives are described.

Summary: After internal data collection and analysis revealed that severe hypoglycemia accounted for 75% of all systematically monitored adverse drug events in its hospital network, St. Louis-based BJC HealthCare designed and executed a multifaceted approach to reducing hypoglycemia events.

Decision Analysis for Metric Selection on a Clinical Quality Scorecard.

Clinical quality scorecards are used by health care institutions to monitor clinical performance and drive quality improvement. Because of the rapid proliferation of quality metrics in health care, BJC HealthCare found it increasingly difficult to select the most impactful scorecard metrics while still monitoring metrics for regulatory purposes. A 7-step measure selection process was implemented incorporating Kepner-Tregoe Decision Analysis, which is a systematic process that considers key criteria that must be satisfied in order to make the best decision.

The cost of serious fall-related injuries at three Midwestern hospitals.

Background: Consequences of fall-related injuries can be both physically and financially costly, yet without current data, hospitals cannot completely determine the financial cost. As part of the analysis for an initiative to minimize falls with injury, the cost and length of stay attributable to serious fall injury were estimated at three hospitals in a Midwestern health care system

Methods: In a retrospective case-control study, 57 hospital inpatients discharged between January 1, 2004, and October 16, 2006, who sustained a serious fall-related injury (fracture, subdural hematoma, any injury resulting in surgical intervention, or death) were identified through the incident reporting system and matched to nonfaller inpatient controls by hospital, age within five years, year of discharge, and diagnosis-related group (DRG).

Results: Multivariate analyses indicated that operational costs for fallers with serious injury, as compared with controls, were $13,316 more (p < .

Inpatients' willingness to recommend: a multilevel analysis.

Background: Satisfaction with health care is one of the most widely assessed measures of hospital care quality, yet studies that account for clustering effects are uncommon. We constructed a multilevel model to identify predictors of willingness to recommend while controlling for clustering effects due to hospital and care unit. We also examined differences in predictors by care unit.

Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.

Background: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) screen for potentially preventable complications in hospitalized patients using hospital administrative data. The PSI for postoperative venous thromboembolism (VTE) relies on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in secondary diagnoses fields. In a clinical validation study of the PSI for postoperative VTE, natural language processing (NLP), supplemented by pharmacy and billing data, was used to identify VTE events missed by medical records coders.

Improving healthcare-associated infection surveillance at a multi-hospital institution using an existing data repository.

The accurate and timely reporting of healthcare-associated infections is an essential infection control practice. Rates provide benchmarks for detecting trends and can help facilities identify intervention opportunities. Standardizing how hospitals within an organization calculate these rates is critical if the rates are to be compared among hospitals and to national standards.

Improving adherence to dyslipidemia medication guidelines in hospitalized diabetic patients using a technology-assisted pharmacist intervention.

We tested whether a technology-assisted pharmacist intervention improved physician adherence to guidelines for lipid-lowering therapy in diabetic patients. Computerized alerts identified diabetic patients above LDL-Cholesterol (LDL-C) goal. During Period 1 prescribing behavior was observed in both control and intervention physician groups without intervening.

Computerized surveillance for adverse drug events in a pediatric hospital.

Adverse drug event (ADE) surveillance is needed to inform processes and methods for prevention. Voluntary reporting and manual chart review have limitations. Automated surveillance systems are gaining recognition and provide useful information to supplement the other methods.

Automated clinical data collection for national quality measurement reporting.

Collecting data for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ORYX Core Measurement Reporting can be automated using an object-oriented, client-developed program that extracts data from a clinical data repository and utilizes an MHA vendor upload process. The process eliminated 39% of the manual data collection efforts.

Natural language processing to identify venous thromboembolic events.

The Agency for Healthcare Research and Quality (AHRQ) has promulgated patient safety indicators to identify potentially preventable adverse safety events, including venous thromboembolism (VTE). Identification of these events for quality reporting is commonly done with AHRQ-defined ICD9-CM codes. We tested a natural language processing service (NLP) as an alternative method of identification.

Physicians' knowledge and attitudes about coronary heart disease secondary prevention.

We administered a knowledge and attitudes questionnaire regarding a technology assisted pharmacist mediated academic detailing intervention designed to improve physician adherence to coronary heart disease (CHD) secondary-prevention guidelines. Questionnaires were administered in two settings: an academic hospital and a community hospital. More knowledgeable physicians reported being more likely to prescribe a pharmacists' recommended medication and to agree that lipid profiles should be automatically performed for inpatients with elevated troponin.

Long-term effectiveness of an automated guideline adherence monitor for secondary prevention of acute myocardial infarction.

An automated guideline monitor for secondary prevention of acute myocardial infarction (AMI) has been favorably tested at an academic medical center using a randomized controlled trial. Subsequently, the monitor was implemented in a production mode and has been in production use for five years. Statistical process control analysis shows a generally sustainable effect of the intervention.

Automated dose checking and intervention for bariatric patients.

According to a recent Center for Disease Control survey, 33% of the US population is obese. Because labeled dosing guidelines are based upon non-obese individuals, under dosing of antibiotics may be problematic in this population. We developed an automated dose checking tool to efficiently detect potentially inappropriate dosing of antibiotics in bariatric (morbidly obese patients).

A technology-assisted approach for discontinuing contact isolation.

While contact isolation can be an effective tool in reducing the transmission of nosocomial methicillin-resistant Staphylococcus aureus (MRSA), it can increase costs and may decrease the quality of patient care. Therefore, it is important to insure that only patients who need contact precautions are isolated. We describe a simple automated report to help infection control practitioners pro-actively identify patients that may no longer need isolation.

Migrating toward a next-generation clinical decision support application: the BJC HealthCare experience.

The next-generation model outlined in the AMIA Roadmap for National Action on Clinical Decision Support (CDS) is aimed to optimize the effectiveness of CDS interventions, and to achieve widespread adoption. BJC HealthCare re-engineered its existing CDS system in alignment with the AMIA roadmap and plans to use it for guidance on further enhancements. We present our experience and discuss an incremental approach to migrate towards the next generation of CDS applications from the viewpoint of a healthcare institution.

Comparison of mortality risk adjustment using a clinical data algorithm (American College of Surgeons National Surgical Quality Improvement Program) and an administrative data algorithm (Solucient) at the case level within a single institution.

Background: There is great interest in efficiently evaluating health care quality, but there is controversy over the use of administrative versus clinical data methods. We sought to compare actual mortality with risk-adjusted expected mortality in a sample population calculated by two different methods; one based on preexisting administrative records and one based on chart reviews.

Study Design: We examined a sample of patients (n = 1,234) undergoing surgical procedures at an academic teaching hospital during 1 year.

Circumstances of patient falls and injuries in 9 hospitals in a midwestern healthcare system.

Objective: Preventing hospital falls and injuries requires knowledge of fall and injury circumstances. Our objectives were to determine whether reported fall circumstances differ among hospitals and to identify predictors of fall-related injury.

Design: Retrospective cohort study.

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

Objective: To characterize pediatricians' attitudes and experiences regarding communicating about errors with the hospital and patients' families.

Design: Cross-sectional survey.

Setting: St Louis, Mo, and Seattle, Wash.

Identification of patients with coronary heart disease: meeting regulatory standards vs. improving overall care.

Acute myocardial infarction (AMI) patients can be identified prospectively by troponin-I (TnI) result monitoring and retrospectively by ICD-9 diagnosis coding. Prospective identification is needed for interventions, while retrospective identification is required for regulatory reporting. Prospective approaches can identify patients with a reasonable degree of accuracy, but they cannot always predict ICD-9 coding for that condition.

Implementing daily dosing rules using a commercial rule base.

We had previously developed and implemented a pharmacy expert system (DoseRanger) that examines drug orders for appropriate single dosage using a commercial rule base and patient specific information. A set of rule adjustments were described and evaluated in order to reduce clinically insignificant alerts. A similar analysis has been performed for daily dose rules provided by the commercial rule base which demonstrated that analogous techniques will be needed.

Voluntary incident reporting tool for a multi-facility environment.

As awareness of medical errors increases, innovative solutions are required to address these errors so that healthcare providers can be proactive rather than reactive. The development of an enterprise-wide voluntary incident reporting application will provide a mechanism to organize and prioritize resources toward correction of processes that could endanger patients.

Implementation of virtual medical record object model for a standards-based clinical decision support rule engine.

The Virtual Medical Record (vMR) is a structured data model for representing individual patient informations. Our implementation of vMR is based on HL7 Reference Information Model (RIM) v2.13 from which a minimum set of objects and attributes are selected to meet the requirement of a clinical decision support (CDS) rule engine.

Improving adherence to coronary heart disease secondary prevention medication guidelines at a community hospital.

Using a two-period group randomized study, we tested whether a technology assisted pharmacist intervention improved physician adherence to coronary heart disease (CHD) secondary prevention medication guidelines. After an observation period, physician practices were randomized to intervention or control arms. In the intervention arm, alerts prompted a pharmacist to communicate with the responsible physician about secondary prevention medications.

Implementing GermWatcher, an enterprise infection control application.

Automated surveillance tools can provide significant advantages to infection control practitioners. When stored in a relational database, the data collected can also be used to support numerous research and quality improvement opportunities. A previously described electronic infection control surveillance system was remodeled to provide multi-hospital support, an XML based rule set, and interoperability with an enterprise terminology server.