Sentinel and Serious Events
New rules for reviewing deaths in hospitals
Every death at the island’s general and psychiatric hospitals is to be scrutinised to check if it was avoidable or unexpected.
The new rules at the King Edward VII Memorial Hospital and the Mid-Atlantic Wellness Institute were introduced in an attempt to improve quality of care.
Senior doctors and nurses have started to meet every week to review the notes of patients who have died in medical care over the previous seven days and to identify those that need investigation.
The Bermuda Hospitals Board will also release statistics every three months on serious incidents that resulted in harm to patients, as well as information on falls, hospital-acquired pressure sores and infections, and other indicators of quality of care.
The new measures are part of an improvement plan drawn up under Michael Richmond, who joined BHB as Chief of Staff in August 2017, in partnership with the Boston-based Institute for Healthcare Improvement.
The safeguards were introduced after it was revealed in July that the island’s general hospital logged 430 incidents resulting in harm to patients over less than five years, with 28 of them falling into the three most serious categories, including 14 deaths.
BHB has now released information on six more serious events over the same period, including another four deaths.
The hospitals board at first released data that showed only 13 events, including six deaths, between 2011 and 2015, after a public access to information request.
It admitted the other incidents after The Royal Gazette complained to the Information Commissioner’s Office that all the records held by the BHB on adverse events had not been disclosed.
Dr Richmond said in July “there was no effort to mislead” and pledged that BHB would publish its incident statistics twice a year in the future.
But he said last week that the statistics would now be reported every quarter, with the first quality report published on the board’s website in October, for the period July 1 to September 30 this year.
Twelve ward-based teams have been set up at KEMH to focus on improvements in the areas of highest patient safety risk, including hospital-acquired pressure sores, falls, medication mistakes and delayed escalation of care.
As well as undergoing training and sharing knowledge with colleagues, the teams were designed to improve “harm reporting”, which Dr Richmond said was voluntary and “incomplete”.
Staff are encouraged to log all events which did, or could have, caused harm to a patient on the BHB’s Quantros computer system, but some are not recorded.
Debra Goins-Francis, the BHB’s general counsel, said an incomplete record was why six more serious events had been identified since the Pati disclosure in July.
She added: “The Bermuda Hospitals Board continues to coach and educate staff as to the importance of recording all safety events in our electronic database.”
Dr Richmond said the new team reviewing deaths was one way to go “looking for trouble” and get better, as was a recent daylong “laborious” session when a team of medics reviewed the files of every patient admitted to the hospital over the course of a month.
He added: “It was roughly about 350 or so patients, going through all of their notes and using a template to determine what were the bad things that had happened.
“It’s a bit like an iceberg. If you only see what’s above the water, you get a false sense of the quality of your performance.
“In high-reliability organisations globally, they don’t believe that the iceberg is only the bit above the water and they then go looking for what’s below the water, which they haven’t seen.”
Dr Richmond said in the past deaths would be investigated if they were known about by senior management, such as through a complaint or because a member of staff logged a report.
He added: “These would be typically the bit of the iceberg above the water, put it that way, which was the stuff that was known about.
“The ‘unknown unknowns’ maybe weren’t being followed with as much diligence as they might.”
Dr Richmond said the new mortality review team was “particularly focused on ... trying to find out where might there have been deaths that were unexpected and avoidable and what are we going to do about it.
“That means getting an early root cause analysis undertaken and to determine first of all ‘was there a failure of care at an individual level or a failure of systemic care?’”
The BHB revealed details this month about the 34 serious events, including the 18 deaths, that happened at KEMH between 2011 and 2015.
The disclosure showed how the patients were harmed and, in some cases, changes made to avoid recurrences.
Dr Richmond said that level of detail would not be given in the quarterly reports, which showed only the number of “serious occurrences” that led to the “death or major and enduring loss of function” for a patient.
He added: “In terms of public disclosure, what we are trying to do is, increasingly, share information.
“In terms of the level of detail, at a personal level, I don’t think that it’s something that any organisation would share, great detail, other than by specific request.
“It wouldn’t be our intention to hide anything and if somebody wanted specific information, which was really around confidential information, then a Pati request is the right way to go.”
He added: “We are looking to be totally transparent about our reliable data. What we are trying to do is to be as transparent and as honest as we can.”
Dr Richmond said injury figures had to be considered in the context of KEMH dealing with about 40,000 emergency patients a year, along with 8,000 operations and 6,000 patient admissions.
BHB quarterly report
The Bermuda Hospitals Board released its first quarterly quality and safety data report in October, with little fanfare to the public.
The board said the four-page report was aimed at providing the public with “good and accurate data to better understand the quality and safety standards at BHB”.
A BHB spokeswoman said: “We will be adding to this portfolio of reliable data over time and we welcome questions and feedback to consider as we build on this first report.”
The report, which covered July 1 to September 30 this year, included a section on “sentinel events” — defined by Accreditation Canada, the BHB’s accreditation body, as “an adverse event leading to death or major and enduring loss of function for a patient”.
The spokeswoman explained: “These are known occurrences from various sources.”
There were no sentinel events reported for the three-month period but Chief of Staff Michael Richmond told The Royal Gazette: “We will certainly have one, if not two, but that’s not reported yet. Our goal is to have zero.”
The report showed:
• 12 falls that caused injury at the King Edward VII Memorial Hospital, Mid-Atlantic Wellness Institute and the Lamb Foggo Urgent Care Centre
• 22 hospital-acquired pressure sores at KEMH. Of those, one was a stage 4 injury, the most serious kind, three were stage 3 and 15 were stage 2. There were three other injuries where the skin was still intact
The BHB spokeswoman said: “One was ‘unclassifiable’ for this reason, but such injuries are usually at least a stage 3. Two could be evaluated as deep-tissue injuries but had unbroken skin so couldn’t be staged. These are potentially serious if not managed”
• 25 cases where patients were readmitted to KEMH inside 72 hours after they were discharged from inpatient care
The report also gave statistics on infections acquired by patients after they have been admitted to the acute care wing of the hospital, with the rate measured in the number of infections per 1,000 patient days, for the past year.
There was a spike in MRSA infections in April and in C. difficile infections between May and July.
In KEMH’s intensive care unit, there was an increase in the number of central line-associated bloodstream infections in patients with catheters in July.
The spokeswoman said there were no central line-associated bloodstream infections up to June 2018 and from August 2018.
She added: “Our infection control department have confirmed that there was only one patient with an infection over the time period reported in the report, represented by the spike in July.”
The average length of stay for patients in the acute care wing was seven days between July and September.
• To view the Bermuda Hospitals Board Sentinel and Serious Injuries Report from 2011 to 2015, click on the PDF link under Related Media