Adverse Event Reporting Takes
Center Stage at
First CORE Meeting
Wrong-site surgeries and the use of old blood for transfusions in pediatric patients are known safety issues. Despite widespread awareness of these problems, such errors still occur.
Looking to reduce the frequency of events like these that result in adverse patient outcomes, representatives from the AAMI Foundation’s Healthcare Technology Safety Institute (HTSI), The Joint Commission (TJC), ECRI Institute, the U.S. Department of Veterans Affairs, industry, Wake up Safe, and the Institute for Safe Medication Practices recently convened at AAMI’s headquarters in Arlington, VA, in the first meeting of the Coalition of Organizations for Reporting Adverse Events (CORE). The focus of the Jan. 29 meeting, facilitated by HTSI, was on how data from adverse event reports could be used to improve clinical practices and device design.
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| Patrick Baird |
Adverse event reporting is handled by various organizations in different ways, and there is no single central reporting system. This fragmentation allows for the potential of missing larger trends. CORE aims to change this situation by informing practice groups, engineers, manufacturers, and others about patterns and trends of adverse events.
“CORE will be a way for patient safety organizations and manufacturers to share trends about adverse event data and identify how to address the causes,” explained Leah Lough, executive director of the AAMI Foundation. Last July, Pat Baird, a systems engineering specialist at Baxter Healthcare, proposed the idea of sharing this information in a neutral environment, with data stripped of identifying information. Participants also will share stories to develop best practices or recommendations.
Over the years, clinicians have been made aware of a number of patient safety issues, yet, as in the case of wrong-site surgeries, the problems continue. TJC, for example, is looking into reports of foreign objects, such as guide wires, drains, and catheter tips, being left in patients. Because it is so difficult for groups like ECRI Institute to communicate with individual hospitals and clinicians, it has proven hard to disseminate information on adverse event trends.
During the day-long CORE event, attendees identified problems and defined goals, objectives, and potential participants for the initiative. Possible wins the group identified included sharing stories of adverse events and “near misses” across organizations and communicating to hospitals about the risks of using outdated equipment and technology.
Another patient safety challenge the group discussed was the use of devices intended for adults on children, according to Donald C. Tyler, MD, executive director of Wake up Safe, who attended the event. The goal of Wake up Safe, a component of the Society for Pediatric Anesthesia, is to improve outcomes for newborns, infants, and children in the perioperative environment.
“Wake up Safe welcomes the opportunity to collaborate with device manufacturers to design better and safer devices for use in children,” he said. “Our members use these devices daily and recognize that there are multiple opportunities for improvement.”
Gerard M. Castro, project director of patient safety initiatives at TJC, said he was looking forward to participating in the group. “What we are trying to do is use our collective resources to better triangulate our understanding of patient safety issues,” he explained. “This group also gives us the opportunity to share what we know—or don’t know—about new or emerging patient safety issues, helping us to direct future efforts.”
The coalition first will concentrate on infusion systems issues. If CORE is successful on this front, it will turn its attention to other types of healthcare technology adverse event data. CORE members will convene once or twice a year to share data and narratives, and a report of these meetings will be made available for free on HTSI’s website.
AAMI News: March 2013, Vol. 48, No. 3