Improving Quality and Safety on a Medical Service: Outcomes from a Divisional Case Review Process

1University of California, San Francisco, San Francisco, CA
2University of California, San Francisco, San Francisco, CA
3University of California, San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 158

Background:

The delivery of safe and high‐quality patient care requires providers to learn from cases involving suboptimal events or outcomes. Although hospitai incident reporting systems generate triggers for case reviews, literature demonstrates insufficient representation of physician utilization of this system. Additionally, new regulatory pressures encourage physician‐led groups to examine their own performance and that of the systems in which they practice. Collecting and analyzing case review data to examine the local needs of a medical service can drive relevant quality and safety initiatives.

Purpose:

We summarize outcomes of our physician led case review process. Specific metrics analyzed include care delivery problems identified, preventabilily of patient harm, and categories of improvement activities which have resulted.

Description:

During the period October 2008‐October 2009, the Division of Hospital Medicine's case review committee members reviewed 63 cases. Thirty percent of these cases were referred by internal faculty, 25% from the medical center, 21% from the hospital's incident reporting system, and the remaining cases from a number of sources including faculty from other departments, house staff, and patient relations representatives. Seventy‐two percent of the cases reviewed by the Division of Hospital Medicine did not have corresponding hospital incident reports. Review of these cases demonstrated that 21 of 63 of The cases (33%) resulted in direct harm to the patient relevant to Hie event in question. In an additional 11 of 63 of cases (17%), incomplete documentation precluded the definitive designation of patient harm directly from the event. Taken together, it is possible that up to 50% of the cases we reviewed could have resulted in direct patient harm. On further study of the 21 cases with definite harm outlined above. 15 (71%) were deemed preventable. Analysis of the case review data revealed 6 major care delivery themes: (1) failure to moniior, observe, or act, (2) delay in diagnosis, (3) delay in obtaining consult or treatment; (4) inadequate communication with consulting services or patient/family; (5) inadequate handoff; and (6) wrong treatment given. The many improvements that have resulted from this process can be categorized into 3 domains: large interdisciplinary endeavors (i.e., discharge process improvement), small safety Task forces (i.e., reduce inpatient aspiration events), and real‐time individual interventions (such as immediate feedback on supervision of residents).

Conclusions:

The assessment of hospital‐based practice through case review and analysis of this data allows the Division of Hospital Medicine to identify trends in patient‐safety hazards and to reveal previously unknown opportunities for quality improvement. These findings inform focused improvement efforts that target both locally relevant challenges along with required quality and safety activities.

Author Disclosure:

L. H. Carr, University of California San Francisco, staff of division of hospital medicine; D. Sliwka, University of California San Francisco, faculty: A, Vidyarthi, University of California San Francisco, faculty, none.

To cite this abstract:

Carr L, Sliwka D, Vidyarthi A. Improving Quality and Safety on a Medical Service: Outcomes from a Divisional Case Review Process. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 158. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/improving-quality-and-safety-on-a-medical-service-outcomes-from-a-divisional-case-review-process/. Accessed July 19, 2019.

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