Objectives: By the end of this call, you will be able to: •Describe the processes of Root-Cause Analysis (RCA) and Multi-Incident Analysis (MIA) and their role in quality improvement •Compare and contrast the different approaches to collecting hospital-acquired VTE data •Identify an approach suitable for improving patient safety at your institution

1. ROOT CAUSE ANALYSIS &
HOSPITAL-ACQUIRED VTE
Artemis Diamantouros, Lynn Riley,
Valentine Valenzuela, Bill Geerts
April 16th, 2015
“Your patient had a VTE – what went wrong?”

2. Welcome to our francophone attendees
Bienvenue à nos participants
francophones
Hélène Riverin
Conseillère en sécurité et en amélioration
Safety Improvement Advisor

3. Objectives
By the end of this call, you will be able to:
1. Describe the processes of Root-Cause Analysis
(RCA) and Multi-Incident Analysis (MIA) and their
role in quality improvement
2. Compare and contrast the different approaches to
collecting hospital-acquired VTE data
3. Identify an approach suitable for improving patient
safety at your institution

4. Today’s Speakers
Bill Geerts Artemis DiamantourosLynn Riley Valentine Valenzuela

5. Agenda
1. Brief primer on root cause analysis (RCA)
2. Measuring performance in VTE prevention
3. Using RCA in VTE prevention quality
improvement

6. Root Cause Analysis
(also called Incident Analysis)
Lynn Riley, RN
ISMP Canada

7. ISMP Canada
ISMP Canada is an independent not-for-profit
organization dedicated to reducing preventable
harm from medications.
Our goal is the creation of safe and reliable systems for
managing medications in all environments.
www.ismp-canada.org

8. www.cmirps-scdpim.ca

9. ISMP Canada

10. How can we analyze incidents
effectively?
Canadian Incident Analysis
Framework (CIAF) 2012
•Updated from Canadian Root
Cause Analysis (RCA)
Framework (2006)
•Developed collaboratively by
CPSI, ISMP Canada,
Saskatchewan Health, Patients
for Patient Safety Canada (a
patient-led program of CPSI),
and with assistance from Paula
Beard, Carolyn Hoffman and
Micheline Ste-Marie

11. Gather
information
Analyze
information
Identify contributing
factors
Develop and prioritize
recommended actions
What
happened?
Why did it
happen?
What can
be done to
reduce the
likelihood of
recurrence?
Implement, Evaluate,
Share Learning
What has
been
learned?

12. The Incident Management
Continuum

13. Incident Analysis Methods
Individual Incident Analysis
• Analysis of an individual incident with the goal
of identifying underlying systems based
contributing factors.
• Includes Comprehensive Analysis and
Concise Incident Analysis
Multi-Incident Analysis
• Analysis of a group of reports involving
common factors pre-defined for achieving a
specific objective

14. Qualitative Analysis Strategies
Described in the Canadian
Incident Analysis Framework
Multi – Incident Analysis:
- Analysis of a group of reports involving common factors pre-
defined for achieving a specific objective
- Method of reviewing several incidents at once instead of one-
by-one, by grouping them in themes (in terms of composition
or origin)
- No, low, or medium harm severity (or near misses)
- Generates valuable organizational and/or system-wide
learning that cannot be obtained through other methods
Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety
Institute; 2012. Incident Analysis Collaborating Parties are Canadian Patient Safety Institute (CPSI), Institute for Safe
Medication Practices Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI),
Paula Beard, Carolyn E. Hoffman and Micheline Ste-Marie.

15. As Part of the CQI Program
Multiple-Incident Analysis can contribute to two key
steps in the CQI process:
- Identify the high impact areas for improvement
- Facilitate the development of effective system and
process enhancements

16. Two Complementary Approaches
Quantitative Analysis (“numbers”)
- Summarize medication incident data
- Descriptive statistics (e.g. frequency distribution
tables)
Qualitative Analysis (“narratives”)
- Analysis of narrative data (“the stories”)
- Qualitative research methods
- Individual Incident Analysis & Multi-Incident
Analysis

17. Summary of Medication
Incident Analysis Strategies
Medication
Incident Data
Quantitative
Analysis
Qualitative Analysis
Individual Incident
Analysis
(Comprehensive &
Concise)
Multi-Incident
Analysis

18. Multi-Incident Analysis:
7 Step Process

19. Summary
Multi-Incident Analysis: Analysis of the narrative data
fields on a group of reports involving a common pre-
defined factor
Maximizes analysis efficiency (analysis of a group of
incidents at a time)
7 Step Process

20. ISMP Canada Workshops
May 20, 2015 Multi-Incident Analysis Workshop –
Toronto
May 22, 2015 Incident Analysis Framework: Train-the-
Trainer Workshop (For PSEP – Canada Trainers in
Ontario LHIN 14) - Thunder Bay, ON
June 11-12, 2015 RCA/FMEA for pharmacy practice -
Toronto
Request a Customized RCA/Incident Analysis
Workshops in English or French
education@ismp-canada.org

21. Tools
The Hospital Self-Assessment for
Anticoagulant Safety (HSASAS) is designed
to:
Heighten awareness of best practices with respect to
anticoagulant safety
Create a baseline for hospital efforts to enhance the
safety of anticoagulant use and assess progress with
respect to these strategies and practices over time.
https://mssa.ismp-canada.org/hsasas

22. We encourage you to report
medication incidents
Practitioner Reporting
https://www.ismp-canada.org/err_report.htm
Consumer Reporting
www.safemedicationuse.ca/

23. Thank you
Lynn Riley
lriley@ismp-canada.org

24. 2. Measuring performance in
VTE prevention
Bill Geerts, MD, FRCPC
Thrombosis Consultant, Sunnybrook Health
Sciences Centre;
Professor of Medicine, University of Toronto;
National Lead, VTE Prevention, Safer Healthcare Now!

25. Assessing the success of
VTE prevention programs
 Essential to measure the impact of patient
safety/QI efforts
Two types of outcomes:
1. Process measures - % of patients at risk for VTE
who receive appropriate thromboprophylaxis
2. Clinical measures – DVT, PE, complications

26. Advantages of auditing adherence
 Simple, fast, inexpensive
 Can largely be done with EPR, electronic pharmacy
records
 Apply standard rules for eligibility, acceptable
thromboprophylaxis options
 Can audit the entire hospital
 Can compare units/services + over time
 Can compare to other centres

27. Unit
type
Total no. patients No. pts excluded Prophylaxis
indicated
Appropriate*
prophylaxis ordered
2012 2013 2014 2015 2012 2013 2014 2015 2012 2013 2014 2015 2012 2013 2014 2015
All
surgical
units
221 233 223 199 46 30 37 57 175 203 186 142 86
%
93% 96% 90%
All
medical
units
207 187 210 209 54 43 63 72 153 144 147 137 78
%
90% 87% 92%
All major
ICUs
44 42 51 48 11 6 9 13 33 36 42 35 94
%
94% 98% 91%
All acute
care units
472 462 484 456 111 79 109 142 361 383 375 314 301
(83%)
351
(92%)
347
(93%)
286
(91%)
Appropriate* Prophylaxis by Unit Groups
*defined as consistent with Sunnybrook policy

28. Limitations of auditing adherence
 Usually limited in scope (single unit/service)
 Usually 1-time snapshots of care
 Usually don’t audit “optimal” prophylaxis but rather
“any” or “on the list” prophylaxis
 If local policy is not optimal, good adherence may not
 improved outcomes
 Surrogate for clinically-important outcomes
 Often targets the wrong audience e.g. RNs,
pharmacists rather than the order writers
 Questionable impact on providers

29. Assessing the success of
VTE prevention programs
 Essential to measure the impact of patient
safety/QI efforts
Two types of outcomes:
1. Process measures - % of patients at risk
for VTE who receive appropriate
thromboprophylaxis
2. Clinical measures – DVT, PE,
complications

30. Methodology of clinical outcome audits
1. Retrospective health records data
2. Real time prospective case finding
3. Real time case finding + feedback

31. 2 types of real-time HA-VTE audits
1. All events (research study)
- very time consuming
2. Representative events (QI initiative)
1
2

32. Limitations of auditing clinical outcomes
(VTE)
 Difficult to find all cases of HA-VTE
 Resource intensive to find cases, review
details, do root cause analysis
 Many HA-VTE occur after discharge
 Relatively small numbers per unit - may
be “underwhelmed” by results

33. Sunnybrook’s approach
1. Retrospective health records data
2. Real time prospective case finding
3. Real time case finding + feedback
 Let’s try to find as many symptomatic, proven HA-VTE
cases as we can
 Try to find them ASAP after the diagnosis
 Do a root cause analysis on these cases
 All the identified cases of HA-VTE go into a database
 Provide timely feedback to the care team if
thromboprophylaxis wasn’t optimal

34. 3. Using RCA in VTE prevention
quality improvement
Val Valenzuela, RN
Thrombosis nurse, Sunnybrook HSC
Artemis Diamantouros, BScPhm, PhD
Knowledge Translation pharmacist, Sunnybrook HSC;
National Coordinator VTE Prevention,
Safer Healthcare Now!
VTE QI in real time

35. Methods
 Case finding: Medical Imaging list of positive leg Dopplers
+ daily Thromboembolism Service
 Cases: symptomatic, confirmed DVT or PE >2 days after
admission and <2 months after discharge
 Standardized root cause analysis of causative and
contributing factors for the event
 Did the patient receive appropriate thromboprophylaxis as
per Sunnybrook policy?
1. Potentially preventable VTE: written feedback to
the patient’s care team
2. “Unpreventable VTE”: enter into HA-VTE database

36. Symptomatic Hospital-Acquired DVT/PE
(>2 days after adm to 2 months after discharge)
Appropriate*
thromboprophylaxis
Suboptimal*
thromboprophylaxis
(=potentially preventable)
Root cause analysis
(causative/contributing factors)
Provide feedback to the care
team
Enter into database
Review our VTE Policy &
Guidelines
*according to Sunnybrook’s Thromboprophylaxis Policy and Guidelines
Excl: upr extrem, abd, CNS, incidental

39. Hospital-Acquired DVT/PE 2011-14
(n= 198; 4.7/month)
Appropriate*
thromboprophylaxis
(133 = 67%)
Suboptimal*
thromboprophylaxis
(=potentially preventable)
(65 = 33%)
Root cause analysis
Provide feedback to the care
team
Enter into database
Review our VTE P&G
1.5/mo
*according to Sunnybrook’s Thromboprophylaxis Policy and Guidelines

40. 0
5
10
15
20
25
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
U-VTE
P-VTE
Hospital-Acquired VTE by Month
(2011-14)
Total/month:
15 12 13 10 12 14 20 29 26 16 18 13

41. 0
5
10
15
20
25
30
Hospital-Acquired VTE by Nursing Unit
(2011-14)
Total/nursing unit:
3 1 2 4 14 1 5 18 38 23 2 2 3 0 2 3 21 33 5 1 1 5 3 6 0 2

42. 0
5
10
15
20
25
30
35
Series
1
Series
2
Hospital-Acquired VTE by Clinical Service
(2011-14)
U-VTE
P-VTE
Total/clinical service:
3 1 0 0 18 48 16 1 17 1 0 24 0 0 28 2 3 5 1 1 0 22 7 0

43. GynOnc GenSur NS Ortho Traum MedOnc CarSur GIM Cardio 2011-13
1.6%
1.4%
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
0
Adm 1,036 3,148 1,536 1,757 2,066 2,852 1,285 8,761 2,591 31,106
HA-
VTE
14 37 15 13 15 14 2 10 0 137
1.35% 1.18% 0.98% 0.74% 0.73% 0.49% 0.16% 0.11% 0 0.44%
Hospital-Acquired VTE by Clinical Service
(2011-13)
 Services with >1000 admissions

44. Potentially Preventable HA-VTE
 65 potentially preventable HA-VTE, July 2011 – Dec 2014
22 (34%)
18 (28%)
15 (23%)
4 (6%)
3 (5%)
2 (3%)
4 (6%)
34%
28%
23%
6%
5% 3%2%
Incorrect dose
Inappropriate delay
No prophylaxis given
TEDs use suboptimal
Inadequate duration
Suboptimal
compliance
Other

45. Limitations of this type of HA-VTE audit
 Underestimates true HA-VTE rates
- OK = we’re not trying to find all events
 Time consuming to find as many cases as is
“reasonable”
- 30-60 minutes/week

46. Benefits of this type of HA-VTE audit
 Identifies clinically-relevant outcomes (“real
patients harmed”)
 Provides insights not seen with other audit
methods
 Real-time feedback (the care team will
know/remember the patient)
 Complements audits of adherence
 Can inform changes in policies and guidelines

47. Mrs. Jones.

48. Take Home Messages
 Root cause analysis is a powerful quality
improvement tool
- Individual incident
- Multi-incident
 RCA can be used in VTE prevention QI
 Provides unique insights into care and can be
used to help change culture
 Keep up the great work – clots can be beaten!

49. “Taking the Pulse” Poll / Sondage

50. Instructions to download certificate
1
2 3
4
5
8
9

51. Thank you!
 Questions; comments/suggestions
 How can Safer Healthcare Now!
help you?
Artemis Diamantouros 416-480-6100 x 3654
Email: artemis.diamantouros@sunnybrook.ca
Bill Geerts
Email: william.geerts@sunnybrook.ca