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A Report to the Patient Safety Committee of Arizona General Hospital. Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005. INTRODUCTIONS. Ashley Mahon Accelerated Option BSN, RN Program

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a report to the patient safety committee of arizona general hospital

A Report to thePatient Safety Committeeof Arizona General Hospital

Prepared by Members of the

University of Missouri-Columbia Interdisciplinary Workgroup



  • Ashley Mahon
    • Accelerated Option BSN, RN Program
    • UMC School of Nursing
  • Russell McCulloh
    • 4th Year, MD Program
    • UMC School of Medicine
  • Kevin Norris
    • 3rd Year, PT Program
    • UMC School of Health Professions
  • Brian Stout
    • 3rd Year, MHA/MBA Dual Degree Program
    • UMC Schools of Medicine & Business
presentation overview
  • Case Overview
  • Methods of Analysis
  • Major Findings
  • Specific Findings
    • Recommendations/Action Plan
    • Tracking Indicators
    • Cost Analysis
  • Systems Issues
  • References/Acknowledgments
case overview
  • Arizona General Hospital:
    • Tertiary care center
    • 620 bed-facility
    • 97 Behavioral Health Beds
  • AGH Values:
    • Dignity
    • Collaboration
    • Stewardship
    • Excellence
case overview6
  • Part of Southwest HC System (SWH)
    • Flagship for HC delivery in Maricopa Co.
    • 10 affiliated clinics
  • Clinical Expertise Centers of Excellence
    • Behavioral Health
    • Women’s Health
    • Rehabilitation
    • Cardiovascular services
    • Neuroscience
    • Oncology
    • Orthopedics
    • Spine Care
case overview7
  • 36 year old female
  • 20 year history of schizophrenia
  • Admitted for decreased mental status
  • Treated for suspected overdose
  • Self-administered medication overdose in hospital
  • 3-week stay in BHU
  • Discharged to home
  • Readmitted seven weeks later for relapse of psychotic symptoms and alcohol intoxication
  • Investigation:
    • Identification of Major Events
    • Causal Flow Analysis
    • Root-Cause Analysis (VA-NCPS)
    • Identification of Contributing Factors
  • Remediation:
    • Literature Review
    • Development of Recommendations
    • Progress Assessment
    • Cost Analysis
    • Extrapolation
major findings
  • Three adverse events were identified:
    • Self-Induced Clozaril Overdose
    • Job/Coverage Loss & Rehospitalization
    • Self-Extubation*
  • Self-Induced Overdose:
    • Unsuccessful suicide attempt
    • Near-miss of a reportable JCAHO sentinel event:

“Any suicide of a patient in a setting where the

patient is housed around-the-clock”

self induced overdose rca
Self-Induced Overdose RCA
  • Root Cause Statement:

“Level of patient observation and

access to potentially toxic medications

resulted in increased possibility

of self-induced overdose.”

  • Three contributing factors domains were identified
self induced overdose contributing factors
Self-Induced Overdose:Contributing Factors
  • Care Team Communication
    • Parallel and informal evaluation and communication of self-harm risk
    • Informal assumption of polysubstance abuse
  • Care Team Roles
    • Medication identified solely by ER staff
    • Primary focus on only physical health aspects of admission
  • Policies & Procedures
    • Persistent access to patient of potentially toxic medications
    • PMH gathered solely from patient’s medication bottle
self induced overdose recommendations
Self-Induced Overdose:Recommendations
  • Care Team Communication
    • AMR “tab” dedicated to psychosocial issues1
  • Care Team Roles
    • All pt home meds are to be ID by pharmacist2
  • Policies & Procedures
    • Develop a standard protocol for evaluation & management of all overdose patients3
    • Establish procedures for pts. at possible risk for self harm1,4
    • Establish security procedures for the intake, storage, and disposition of pt home meds2
    • Similar policy for potentially harmful pt. items2
self induced overdose tracking indicators
Self-Induced Overdose:Tracking Indicators
  • Suspected overdose patients assessed for self-harm risk*
  • Employees scoring 70% or greater on knowledge assessment of behavioral health training courses*
  • Home medications stored securely*

*All indicators are percentage-based; goals for implementation are to be set at 100% compliance

self induced overdose cost analysis
Self-Induced Overdose:Cost Analysis
  • Incurred costs
    • Room sitters (personnel-dependent)
    • Time/resource demands for training personnel re: new assessment procedures
    • Monitoring/ongoing risk assessment
  • Cost-neutral measures
    • AMR changes covered by IT contract
  • Estimated savings
    • Reduced risk of emergent intervention
job coverage loss rehospitalization rca
Job/Coverage Loss & Rehospitalization RCA
  • Root Cause Statement :

“Level of social services involvement led to the patient’s job & coverage loss and ultimately resulted in patient’s relapse & readmission to the hospital.”

  • Three contributing factor domains were identified
job coverage loss rehosp contributing factors
Job/Coverage Loss & Rehosp.:Contributing Factors
  • Care Team Communication:
    • Care teams engaged in parallel and informal communication
  • Coordination of Social Services:
    • Patient assigned to HCC
    • Currently defined roles for HCC and SW
    • HCC only involved near end of pt’s stay
  • AMR Usage:
    • Hospital staff unfamiliar with documenting psycho-social information into the AMR
    • Incomplete integration of AMR with organizational culture
job coverage loss rehosp recommendations
Job/Coverage Loss & Rehosp.:Recommendations
  • Care Team Communication
    • Psych team and SW make daily rounds together for all primary diagnoses of mental illness, psychosis, and drug overdose5
    • Fully integrated multi-disciplinary teams
  • Coordination of Social Services
    • Redefine the role of the HCC6,7,8
    • Automatic referral to SW in cases with primary dx. of mental illness, psychosis, or drug overdose
  • AMR Usage
    • AMR “Tab” for psycho-social information
    • Formal mechanism for staff feedback
job coverage loss rehosp tracking indicators
Job/Coverage Loss & Rehosp.: Tracking Indicators
  • Staff satisfaction rate with AMR (20% increase from baseline)
  • Voluntary exit survey for patients receiving Psych/SW team care
  • Percent of pts. admitted with diagnosis of mental illness, psychosis, or drug overdose, assessed by SW (100%)
  • Percent of pts seen by HCC within:

- 36 hours of admission (>95%)

- 48 hours of admission (100%)

5. Number of readmissions due to mental illness, psychosis, or drug overdose (10% reduction)

job coverage loss rehosp cost analysis
Job/Coverage Loss & Rehosp.: Cost Analysis
  • Cost Neutral Recommendations:
    • AMR changes (provided through IT contract)
    • Social Worker/Psych rounds
    • Referral policies
  • Incurred Costs
    • Additional HCCs (case managers)9
  • Savings
    • Reduce number of psych readmissions6
    • Reduced LOS by 10% with multi-disciplinary rounds5
    • Reduced per-patient cost of stay by up to 16% with multi-disciplinary rounds5
self extubation rca
Self-Extubation RCA
  • Root Cause Statement :

“The level of sedation & agitation

management increased the likelihood

of patient self-extubation”

  • Three major contributing factor domains were identified
self extubation contributing factors
Self-Extubation:Contributing Factors
  • Care Team Communication:
    • Time/location of pharmacist involvement
    • Communication b/w front-line providers
  • Policies & Procedures:
    • Extent of behavioral assessment
    • Availability/use of agitation management protocols
    • Availability/use of sedation and weaning protocols
  • Scheduling:
    • Provider staffing-level in ICU
self extubation recommendations
  • Care Team Communication:
    • Ensure timely urine/serum toxicology screens in conjunction with overdose protocols
    • Develop AMR flag for pharmacist consult in all cases involving drug overdose
  • Policies & Procedures:
    • Institute routine use of agitation management protocols by ICU staff (Ramsay)10
    • Institute use of sedation protocols in ICU11,12
    • Institute use of weaning protocols in ICU10,13
  • Scheduling:
    • Evaluate adequacy of ICU staffing/training10,14,15
self extubation tracking indicators
Self-Extubation:Tracking Indicators
  • Incidence of self-extubation (ICU)
  • Length of ventilator support (ICU)
  • ICU pt-nurse staffing ratios (1.5-1.7)
  • Number of pts (per 100 intubated pts) that score below 3 on two consecutive hourly Ramsay Assessments (Zero)
  • Percent of overdose pts whose records include RPh consult notes (100%)
  • Percent of overdose pts whose urine/serum toxicology screens are ordered w/in 1 Hr of admit to ER (100%)
self extubation cost analysis
Self-Extubation:Cost Analysis
  • Incurred Cost:
    • Increased ICU Staffing?
    • Physician/RPh Consult Fees
    • Implementation of protocols/training
    • Monitoring/ongoing risk assessment
  • Estimated Savings:
    • Decreased LOS in ICU (Decrease of 3.5 days)16,17
    • Shorter Duration of Ventilator Support (Decrease of 2.5 days17; between 63 and 89% of SEs do not require reintubation10)
    • Costs of Reintubation (>40% Decrease)11
recommendation summary
Recommendation Summary
  • Communication
  • AMR/organizational culture integration
  • Policies and Procedures
  • Expansion of care team member roles
  • Supporting AGH mission and values
    • Dignity
    • Collaboration
    • Stewardship
    • Excellence
what if
What If…
  • Psych would have been more actively involved in patient care?
    • Risk for self-harm would have indicated need for 1:1 staffing and/or suicide observation in ICU and suicide observation in Ward 10A
  • Pharmacy would have been more actively involved in patient care?
    • Patient and drug ID would have been confirmed
    • Patient PMH might have been available
    • Concerns over sedative interactions might have been dismissed
what if53
What If…
  • Social Services would have been more actively involved in patient care?
    • Patient job/coverage loss might have been avoided altogether
    • Patient would have had access to local mental health resources and “safety net” coverage
  • All three domains had been aligned with delivery of acute care?
    • No adverse events?
    • Patient would have certainly left our institution better off than when she arrived (in many ways)
targeting continuity of mental health services
Targeting Continuity of Mental Health Services
  • Within the Institution
    • Mental Health Services
    • Pharmacy
    • Social Services
    • Acute/Chronic Care
  • Within the Community:
    • Provider/MCO Collaboration
    • Partnerships
    • Regional Leadership
future directions
Future Directions:
  • Increase pharmacy integration:
    • Discharge Planning/Consultation18,19,20
    • Pharmacy and Therapeutics Committee18,19
    • Collaborative Drug Therapy18,19
    • Medication Reconciliation21
    • Psychiatric Pharmacist22,23
  • Integrating social services & behavioral health:
    • Functional Integration Team18 (AGH BHCE)
    • Wellness Recovery Action Plans24 (WRAP)
  • Ongoing collaboration between:
    • AGH & community pharmacies
    • AGH & satellite clinics
    • SWH & ValueOptions25,26
concluding remarks
Concluding Remarks
  • Consistent with:
    • Our institutional mission
    • IOM & IHI vision of the future
    • Our patients’ needs/rights to access & receive safe, reliable, and comprehensive care

“It doesn’t work to leap a twenty-foot chasm

in two ten-foot jumps”

-American Proverb

a report to the patient safety committee of arizona general hospital57

A Report to thePatient Safety Committeeof Arizona General Hospital

Prepared by Members of the

University of Missouri-Columbia Interdisciplinary Workgroup



  • Dlugacz, Y.D., Restifo, A., Scanion, K., Nerlson, K., et al. (2003). Safety Strategies to Prevent Suicide in Multiple Health Care Environments. Joint Commission Journal on Quality and Safety, 29(6), 267-278.
  • Harry S. Truman Memorial Veterans Hospital- Pharmacy operations and drug procedures. December 30, 2004.
  • Harry S. Truman Memorial Veterans Hospital- Prevention and management of disturbed behavior. April 22, 2004.
  • Harry S. Truman Memorial VeteransHospital- Management of suicidal policy. April 26, 2004.
  • Curley, C., McEachern, K. E., Speroff, T. (1998). A Firm Trial of Interdisciplinary Rounds on Impatient Medical Wards: An Intervention designed using continuous quality improvement. Med Care, 36(8), AS4-AS12.
  • Cox, W.K., Penny, L.C., Statham, R.P., Roper, B.L. Admission intervention team: medical center based intensive case management of the seriously mentally ill. Care Management Journals, 4(4), 178-184.
  • Rubin, A. Is Case Management Effective for People With Serious Mental Illness? A research review. Health & Social Work, 17(2), 138-150.
  • Wickizer, T.M., Lessler, D. Do Treatment Restrictions Imposed by Utilization Management Increase the Likelihood of Readmission for Psychiatric Patients? Medical Care, 36(6), 844-850.
  • 2003 Case Management Salary Survey Results. In: Advance for Providers of Post-Acute Care. May/June 2003, 51-54.
  • Maccioli GA et al. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies-American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 31(11), 2665-2676.
  • Wagner IJ. (1998). A sedation protocol to prevent self-extubation. Chest. 113(5),1429.
  • Powers J. (1999). A sedation protocol for preventing patient self-extubation. Dimensions of Critical Care Nursing. 18(2), 30-4.
  • Razek T et al. (2000). Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. Journal of Trauma-Injury Infection and Critical Care. 48(3), 466-9.
  • Bray K et al. (2004). British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. BACCN Nursing in Critical Care. 9(5), 1-19.
  • Martin B and Mathisen L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care. 14, 133-142.
  • Ramsay MAE. (2005). How to use the Ramsay Score to address the level of ICU sedation. Referenced Wed Document. Available at: http://5jsnacc.umin.ac.jp/How%20to%20use%20the%20Ramsay%20Score%20to%20assess%20the%20level%20of%20ICU%20Sedation.htm. Accessed on March 23rd, 2005.
  • Kress JP, Pohlman AS, and Hall JB. (2002). Sedation and analgesia in the intensive care unit. American Journal of Respiratory Critical Care Medicine. 166, 1024-1028.
  • IHI 100,00 Lives Campaign. (2004). Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation). The Institute for Health Improvement. Available at www.ihi.org.
  • Paone D, Levy R, and Bringewatt R. (1999). Integrating pharmaceutical care: a vision and a framework. The National Chronic Care Consortium & The National Pharmaceutical Council. Available at www.npcnow.org/resources/PDFs/IPCvisionpaper.pdf.
  • Saunders, S.M., Tierney, J.A., et al. (2003). Implementing a pharmacist-provided discharge counseling service. AMJHSP, 60, 1101-1103.
  • Rosen CE and Holmes S. (1978). Pharmacist’s impact on chronic psychiatric outpatients in community mental health. American Journal of Hospital Pharmacy. 35(6), 704-8.
  • Kaushal R and Bates DW. (2005). Chapter 7: The clinical pharmacist’s role in preventing adverse drug events. AHRQ Patient Safety Manual. Available at www.ahrq.gov/clinic/ptsafety/chap7.
  • Arizona State Hospital. Wellness Recovery Action Plans (WRAP). http://www.azdhs.gov/azsh/patient_programs.htm.
  • ACP-ASIM. (2000). Pharmacist Scope of Practice. Position Paper. American College of Physicians – American Society of Internal Medicine. www.acponline.org/hpp/pospaper/pharm_scope.pdf.
  • ValueOptions of Arizona. Assertive Community Treatment (ACT). http://www.valueoptions.com/arizona/en/programs/act.htm
  • ValueOptions of Arizona. Contract implementation fact sheet: Recovery for adults with serious mental illnesses. Available at: http:// www.valueoptions.com/arizona/en/publications/fact_sheet_adult.pdf.
data sources for cost analyses
Data Sources for Cost Analyses
  • A - University Health System Consortium Clinical Database; January through December 2004 (Drawn from 9 geographically dispersed academic medical centers, bed size from 616 to 692, average # of beds = 660; when applicable, adjusted for 620 bed institution)
  • B - Annual Salary from: 2003 Case Management Salary Survey Results. Published in: Advance for Providers of Post-Acute Care; May/June 2003, 51-54.
  • C - University of Missouri Health Care, University Hospital; January through December 2004. (Identified at group request by the UMHC Office of Clinical Effectiveness; when applicable, adjusted for 620 bed institution)
  • D - Medicare Fee Schedule – 2004 (Intubation – Endotracheal Emergency – Code 31500)
  • Kristofer Hagglund, PhD. Dean of Health Policy. School of Health Professions. University of Missouri-Columbia.
  • Kathryn Nelson, MHA. Patient Safety Officer. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital.
  • Betty Nikodim. Senior Analyst. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital.
  • Tim Anderson, RN. Patient Safety Manager. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.
  • Barb Aston, MSW. Social Worker (Retired). Mid-Missouri Mental Health Center.
  • Kathryn Burks, RN, PhD. Faculty Advisor. University of Missouri-Columbia Sinclair School of Nursing.
  • Charles Brooks, MD, FACP. Residency Director. Department of Internal Medicine. UMC School of Medicine.
  • Rachel Haverstick, MA. Executive Staff Assistant. Center for Health Care Quality. University of Missouri-Columbia.
  • Laurel Despins, MS, APRN, BC, CCRN. Project Director. Office of Clinical Effectiveness. Clinical Nurse Specialist, Medical-Neurosurgical ICU. University of Missouri-Columbia.
  • Mark Kruse. Medical Records. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.
  • Rebecca Wirth, MSW. Social Worker. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.
  • Deborah Hurley. Human Resource Associate. Department of Health Management and Informatics. UMC School of Medicine.
  • Jane Bostick, RN, PhD. Faculty Advisor. UMC Sinclair School of Nursing.
  • Linda Headrick, MD. Sr. Associate Dean for Education. University of Missouri-Columbia School of Medicine.
contact information
Contact Information
  • Presenter Contact information:
    • Ashley Mahon: aem7ee@mizzou.edu
    • Russell McCulloh: rjm42b@mizzou.edu
    • Kevin Norris: kdn337@mizzou.edu
    • Brian Stout: bjs13e@mizzou.edu
  • UMC CLARION group was coordinated through the University of Missouri-Columbia Center for Health Care Quality (CHCQ)
    • For more information, please contact:

Rachel Haverstick, Executive Staff Assistant.

UMC Center for Health Care Quality

Medical Sciences Building, MA128

University of Missouri-Columbia. Columbia, MO 65211

Voice: (573) 882-8905

Fax: [573] 884-0474

Email: haverstickr@missouri.edu.