Adverse events and in-hospital mortality: An analysis of all deaths in a Norwegian Health Trust during 2011

Transkript

1 Adverse events and in-hospital mortality: An analysis of all deaths in a Norwegian Health Trust during 2011 Bjørn Arild Alme, Sidsel Aardal, Guttorm Brattebø, Asgaut Viste, Bjørn Bertelsen, Stig Harthug, Jan Rosland, Hans Flaatten Haukeland University Hospital

2 Nasjonalt Kunnskapssenter for Helsetjenesten 2011: A national patient safety study using Global Trigger Tool publised a rapport with unverified numbers: 0.66% of all hospital admissions resulted in a patient injury that lead to death. This translated to 4500 patients.

3 Rapport: deaths dødsfall caused skyldes by sykehusskader hospital injuries «FLINKEST»: Nestleder Øyvind Skraastad på Akuttklinikken ved Oslo universitetssykehus (OUS) følger her med på en hjerteoperasjon. OUS har det laveste antallet pasientopphold med personskade som er kartlagt så langt. Foto: JØRGEN BRAASTAD Av INGUNN SALTBONES, MAY LINN GJERDING og BODIL SUNDBYE (VG) :20 Halvparten av de rundt 4500 dødsfallene som skyldtes skader på sykehus i fjor, kunne vært unngått. Det fremgår av en foreløpig rapport fra. for helsetjenesten last har year VG følger utarbeidet for myndighetene. For første gang er omfanget av Sykehus-Norge pasientskader som skjer på norske sykehus kartlagt. Det er gjort ved å granske journaler - og funnene er rystende: Cirka 0,6 prosent 4500 died from injuries in Norwegian hospitals Vet du noe om saken? Tips VG! I fjor døde om lag 4500 pasienter i Norge som følge av skade som oppsto på norske sykehus, ifølge den ferske rapporten. Det utgjør rundt 0,6 prosent av alle pasienter. MMS/SMS: 2200 E-POST: 2200@VG.NO TLF:

4 Objective Identify causes of death all deceased patients Study the magnitude of unexpected deaths assosiated with adverse events in a Norwegian health trust.

5 Haukeland University Hospital 968 beds Local hospital for Referral hospital for The Health Trust Haraldsplass Deaconess Hospital 161 beds Community Hospital Voss Hospital 60 beds Community Hospital

6 Deaths in the health trust in 2011 Medical files for all deceased patient in the three hospitals in 2011 were retrived from our electronic administrative and medical record system. The files were examined individualy by 4 investigators. Expected deaths were identified: The patient was in the final stage of a severe, cronic or terminal disease and the death was forthcomming. Such a condition was diagnosed during the stay. Sudden and/or Unexpected deaths All other deaths

7 Sudden and / or Unexpected deaths Classified as natural or un-natural deaths according to Norwegian law «2 Regulations for physicians report to the police about unnatural deaths»: Error, omission, or accidents related to diagnosis or treatment of disease or trauma Unknown causes when the deaths has occured suddenly and unexpectedly Murder or other trauma to the human body Suicide or self-inflicted damage to the body Accidents, including capsizin, burns, avalanche, lightning strikes, drowning, traffic-realted incidents Occupational accidents Use of illegal drugs All deaths occuring in civil og military prisons Finding of a unknown corpse

8 Deaths in the health trust in 2011 For all deaths there was registrered: Age Gender Hours to death from hospital admission, Department responsible for patient s care at time of death Charlson Comobidity Index

9 Deaths in the health trust in patients admitted 1186 registrered deaths (1.98%) Expected 896 Sudden and/or Unexpected 290 (24.5%) Natural 220 Un-natural 70 (5.9%)

10 Deaths in the health trust in 2011 No Age Mean (median) CCI Mean LOS days Mean (median) Died in ICU % All (78) (5.6) 11.6 Expected (78) (6.3) 8.7 Un-Expected (79) (2.7) 20.3 Natural (79) (2.1) 18.8 Un-natural (69) (3.9) 25.7

11 Patient Safety Unit Intensive Care Medicine Surgey Anesthesiology Consensus Group Pathology Emergency Care medicine Internal Medicine

12 Un-natural Deaths Cause of death and signs of any adverse events during the hospital stay were investigated. Preventability was determined using a Likert Scale Preventable No % all deaths Not preventable % Probably not 6 0.5% Uncertain % Probably % Certain preventable 5 0.4%

13 Deaths in the Health Trust in 2011 Among admitted patients we identified 16 deaths that was judged as possible preventable or preventable % of all admissions 1.3% of all deaths National patient safety rapport: 0.66% of all admissions resultet in a patient injury that lead to death 1/3 of all deaths in hospital caused by patient injury

14 Admissions near the end of life Cause of death is often a complication Airway infection Aspiration Respiratory failure Although to som extend preventable, this is not causes that we necessarily aim to prevent or correct It is mainly in the group of unexpected deaths that the term lethal adverse event is meaningful «Errors of Omission» might be more important to registrer and correct in this group of patients

15 Errors in treatment High Risk treatment Complications Adverse event Lifesaving treatment Cause of death

16 Limitations Retrospective analysis does have limitations Detailed information might not always be adequately documented The investigators might have been to strict with regards to the definition of an unexpexted death The reference panel might have been to strict to judge an adverse event as non-preventable. All participants were from Haukeland University Hospital and Haraldsplass Deaconess Hospital

17 Netherlands admissions of deceased patients 10.7% adverse events 4.1% preventable

18 United Kingdom deceased patients 5.2% of deaths having a > 50% probability of being preventable

19 Conclusion GTT is probably an inaccurate tool for detecting rare occuring events as death due to patient injuries. Any such random estimations should be compared to a gold standard. We belive that our study does provide a golden standard for our region conserning the distribution of deaths according to our national criteria.

20 Conclusion If the aim is to estimate the portion of adverse events contributing to death, we recommend studying the population of patients who died and then finding the cause of death.