As healthcare organizations continue to experience expenses growing faster than revenues, value based care, and consumer transparency of costs and quality, patient safety will be an important determinant of success. This session will describe the sociotechnical attributes of a safe system, the challenges, the barriers and opportunities, and how to use data and your culture of safety as a powerful tool to drive down adverse events. Attendees will learn: Why patient safety and quality are important. How data can help improve patient safety. The history of patient safety and where we are today. What components make up a safety analytics culture. How the internal safety culture directly impacts patient safety metrics. To describe basic guidelines for improving a safety culture with analytics.

1. Stanley L Pestotnik, MS, RPh
Valere Lemon, MBA, RN
How to Use Data to
Improve Patient Safety:
A Two-Part Discussion

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Agenda
2
History and myths
about patient safety
and quality.
Roadblock to
patient safety.
How data and
analytics can help.

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The prevention of harm caused by errors
of commission and omission.
Patient Safety Defined:
Adverse event defined:
An event that results in unintended harm (injury) to
the patient by an act of commission or omission
rather than the underlying disease or condition of the
patient.
Source: Institute of Medicine, Patient Safety: achieving a new standard for care,
The National Academies Press, 2004

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Patient Safety
5
The
human
faces

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Pioneers in Patient Safety
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0
2
4
6
8
10
12
14
16
18
1841 1842 1843 1844 1845 1846 1847 1848 1849 1850
MaternalMortality
First Second
Intervention
Semmelweis IP, 1861
May 15, 1847
Maternal Mortality Rates
First and second obstetric clinics
General Hospital of Vienna, 1841-1850
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Poll Question #1
Within the United States, since the 1999 IOM report on patient
safety, preventable harm in the US has: 79 respondents
a. Decreased 10 fold – 7%
b. Decreased by half – 20%
c. Stayed the same – 28%
d. Increased by half – 28%
e. Increased 10 fold – 16%
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Please rate your organization’s use of data to drive patient safety
and quality improvement. 76 Respondents
a. Extremely effective – 5%
b. Very effective – 19%
c. Effective – 41%
d. Not very effective – 27%
e. Ineffective – 8%
Poll Question #2
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When using data to improve patient safety and quality, the data in my
organization is: (check all that apply) 75 Respondents
a. Timely – 34%
b. Automated – 42%
c. Actionable – 45%
d. Using predictive analytics – 23%
e. None of the above – 29%
Poll Question #3
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Preventable medical injuries are
actually on the rise.
Ten times more preventable
harm since 1999.
• 400,000 lives per year.
• >$100B annually.
Patient harm is the 3rd leading
cause of death.
Dispelling Myths about Patient Safety
11
Based on our estimate,
medical error is the 3rd
most common cause of
death in the US.
However, we’re not even
counting this – medical
error is not recorded on
US death certificates.
Causes of death—U.S., 2013
Heart
disease
611k
Cancer
585k
Medical
error
251k
COPD
149k
All causes
2,597 k
Suicide
41k
Firearms
34k
Motor
vehicles
34k

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 Information management in
EHRs
 Unrecognized patient
deterioration
 Implementation and use of
clinical decision support
 Test result reporting and follow-up
 Antimicrobial stewardship
 Patient identification
 Opioid administration and
monitoring in acute care
 Behavioral Health issues in non-
Behavioral-Health settings
 Management of new oral
anticoagulants
 Inadequate systems or
processes to improve safety
and quality
2017201620152014
 Health IT configurations and
organizational workflow that
do not support each other
 Patient identification errors
 Inadequate management of
behavioral health issues in non-
Behavioral-Health settings
 Inadequate cleaning and
disinfection of flexible
endoscopes
 Inadequate test result reporting
and follow up
 Inadequate monitoring for
respiratory depression in
patients prescribed opioids
 Medication errors related to
pounds and kilograms
 Unintentionally retained objects
despite correct count
 Inadequate antimicrobial
stewardship
 Failure to embrace a culture
of safety
 Alarm hazards: inadequate
alarm configuration policies and
practices
 Data integrity: incorrect or
missing data in EHRs and
other health IT systems
 Managing patient violence
 Mix-up of IV lines leading to
misadministration of drugs and
solutions
 Care coordination events related
to medication reconciliation
 Failure to conduct independent
double checks independently
 Opioid-related events
 Inadequate reprocessing of
endoscopes and surgical
instruments
 Inadequate patient handoffs
related to patient transport
 Medication errors related to
pounds and kilograms
 Data integrity failures with
health information technology
systems
 Poor care coordination with
patient’s next level of care
 Test results reporting errors
 Drug shortages
 Failure to adequately manage
behavioral health patients in
acute care settings
 Mislabeled specimens
 Retained devices and retrieved
fragments
 Patient falls while toileting
 Inadequate monitoring for
respiratory depression in
patients taking opioids
 Inadequate reprocessing of
endoscopes and surgical
instruments

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Poll Question #4
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How effective are your organization’s patient safety improvement
programs? 76 Respondents
a) Not at all effective – 3%
b) Somewhat effective – 31%
c) Moderately effective – 40%
d) Very effective – 13%
e) Unsure or not applicable – 14%

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Berwick’s Roadblocks to Improving Patient Safety
14
Displacement
by other
concerns.
Thinking
incentives will
improve
quality.
Metrics Glut.
Illusion of
completeness.
Separation of
safety from
quality.
System
literacy.

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Creating a System of Learning and Safety
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Socio-
Economic
Financial
Admin
Clinical
(EHR/Device)
Patient
Reported
Active
Surveillance
Data
Operating
System
Normalize
Standardize
Optimize
Algorithms
Thoughtflow
Text analytics
Machine learning
1. Triggers
2. Clinical Confirmation
3. RCA with Attribution
Insight &
Learning
Dashboards
Reports
Exports
Prediction and
Prevention
Actionable
Interventions &
Sustained
outcomes
Patient Safety Surveillance Value Chain:

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How Data and Analytics Can Improve Patient Safety
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Reactive
capabilities
Automated triggers
identify potential harm.
Proactive
capabilities
Predictive analytics
identifies interventions
to reduce or prevent
harm.
Full integration
capability
Safety tool integrated
across workflow tools
across the health
system.

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Using Data and Analytics to Improve Patient Safety
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Analytic
efficiencies –
automation and
integration.
New insights
for performance
improvement.
35% decrease
in HACs.
50% decrease
in CAUTI rate.
75% decrease
in manual chart
reviews.
5.3% percentage point
reduction (a 21.7% relative
reduction) in incidence of
bleeding after PCI and
$1.8M cost reduction.
7% relative improvement in
percentage of patients
therapeutic within 24 hours
of heparin therapy;
decreased incidence of
major bleeds.

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Using Data and Analytics to Improve Patient Safety
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Pain Management Trigger
Morphine Milligram
Equivalents per day > 50
Population Analytic

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Pain Management Trigger
Morphine Milligram
Equivalents per day > 50
Patient Analytic
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The Future of Safety
A Sociotechnical Solution
Retrospective safety information
• Detect fraction of all events.
• Labor intensive and unwieldy.
Frontline drenched with alerts
• More burn-out.
• More cynicism.
• More risk.
Poor clinical learning systems
• Hard to use to change patterns.
Other issues
• Safety isolated from hospital
business.
• Safety data black-hole.
Health Catalyst
Approach
Existing
Systems
Real-time safety analytics
• Measure, trend, and learn from all defects.
• Predict harm in specific patients and
populations.
Intelligent & clinically appropriate
• Targeted intervention.
• System of trust.
• Controlled risk.
Data-driven learning systems
• Integration of culture and analytics.
• Learning boards (organizational, unit and
patient).
• Focus on integrated value.
• Transparency (sharing safety data with
patients).

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Date: June 28th
Time: 1:00-2:00 PM EST
Attendees will learn how to:
• Get upstream of patient safety events to avoid harm and
downstream costs.
• Identify key sources of patient safety data.
• Integrate patient safety data into existing quality improvement
projects.
• Improve patient safety using real-time safety analytics.
Join for the Second Part of this Discussion
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Healthcare Analytics Summit 17
ERIC J. TOPOL
Author, The Patient Will
See You Now and The
Creative Destruction of
Medicine. Director,
Scripps Translational
Science Institute
DAVID B. NASH,
MD. MBA
Dean, Jefferson
School of
Population
Health
JOHN MOORE
Founder and Managing
Partner, Chilmark Research
ROBERT A. DEMICHIEI
Executive Vice President and
Chief Financial Officer, University
of Pittsburgh Medical Center
THOMAS D.
BURTON
Co-Founder, Chief
Improvement Officer,
and Chief Fun Officer,
Health Catalyst
DALE SANDERS
Executive Vice
President, Product
Development,
Health Catalyst
THOMAS DAVENPORT
Author , Consultant
Competing on Analytics*, ,
Analyitcs at Work, Big Data at
Work, Only Humans Need
Apply:Winners and Losers in the
Age of Smart Machines.
*Recognized by Harvard
Business Review editors as one
the most important management
ideas of the past decade, one of
HBR’s ten must-read articles in
that magazine’s 90-year history.
Summit highlights
Industry Leading Keynote Speakers
We’ll hear from well-known healthcare visionaries. We’ll also
hear from two C-level executives leading large healthcare
organizations.
CME Accreditation For Clinicians
HAS 17 will again qualify as a continuing medical education
(CME) activity.
30 Educational, Case Study, and Technical
Sessions
We have the most comprehensive set of breakout sessions of
any analytics summit. Our primary breakout session focus is
giving you detailed, practical “how to” learning examples
combined with question and opportunities.
The Analytics Walkabout
Back by popular demand, the Analytics Walkabout will feature
24 new projects highlighting a variety of additional clinical,
financial, operational, and workflow analytics and outcomes
improvement successes.
Analytics-driven, Hands-on Engagement for
Teams and Individuals
Analytics will continue to flow through the three-day summit
touching every aspect of the agenda.
Networking and Fun
We’ll provide some new innovative analytics-driven
opportunities to network while keeping our popular fun run and
walk opportunities and dinner on the down.
Sept. 12-14, 2017
Grand America Hotel
Salt Lake City, UT