Eliminating Preventable Harm at BIDMC

The BIDMC initiative to eliminate all types of preventable harm is unique, and has required that we develop our own methodology for assessing "harm" and whether that harm was "preventable."

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This methodology is distinct and separate from the BIDMC peer review process, which may apply different criteria. We are disclosing our progress so that others can learn from our experience, but we recognize that we are still learning ourselves, and therefore our methods and results are likely to change over time. For example, if we improving our methods for detecting harm, the numbers of events may increase and we will need to revise the numbers reported here accordingly.

Context

Many have asked why BIDMC would choose to voluntarily and publicly report the occurrence of harm. We do so because — given it is a known fact that harm occurs at all hospitals — our best opportunity for eliminating harm comes from shared learning. When reviewing our performance, it is worth keeping in mind the volume of clinical care that occurred during this time frame. In any given year, if one totals outpatient visits, procedures, and inpatient hospitalizations, there are approximately 1,000,000 distinct patient encounters at BIDMC.

BIDMC's definition of harm targeted for elimination

Unintended physical or emotional injury in association with medical care (including the absence of indicated medical treatment) that requires or prolongs hospitalization and/or results in permanent disability or death.

BIDMC process for assessing "preventable"

For any specific case, it may be impossible to establish with certainty what specific actions could have prevented harm. Our philosophy, therefore, is to use a theoretical approach that focuses on the opportunity to prevent future harm, as opposed to determining the cause of a past event. BIDMC classifies an injury as preventable if it allows us to identify reasonable improvements in care that would help decrease the likelihood of similar events occurring in the future. BIDMC has defined several subcategories of harm, and evaluates events in relation to established criteria for each category to decide whether they qualify as "preventable."

Lessons Learned

Our review of cases has led us to make the following improvements in our practice at BIDMC:

• More thorough review of cardiac arrests at BIDMC.
• Automation of the way that hospitalized patients receive therapy to prevent blood clots.
• Continued aggressive focus on best practices for preventing infection in hospitalized patients.
• Utilizing technologies in patient medication administration and management.
• Implementation of nursing programs to prevent patient falls.  

As part of our progress and reports to the community, BIDMC has posted a video that chronicles three stories that represent how the issue is being addressed. Below are the details on all of the areas of preventable harm we track.

Preventable Harm Indicators

Hospital Acquired Central Venous Catheter Associated Bloodstream Infections

Hospitalized patients that need lots of intravenous fluids or medicines sometimes need a catheter placed in a larger, central vein. These catheters are prone to infection, but risk of infection can be decreased by following best practices for inserting and maintaining the catheter. Infections are diagnosed according to the Center for Disease Control definitions through review of positive blood cultures.

Hospital Acquired Surgical Site Infections

This includes infections at the surgical site in patients who had surgery at BIDMC. Surgical site infections meeting definition of "harm" are diagnosed according to the Center for Disease Control definitions for "deep" and "organ space" infection. Learn more about our efforts to reduce surgical site infections at BIDMC.

Hospital Acquired Ventilator Associated Pneumonia

Patients maintained on a ventilator are prone to getting pneumonia, but the risk of pneumonia can be reduced by following best practices for bedside respiratory care. Ventilator-associated pneumonia is diagnosed according to Centers for Disease Control definitions, and any case where best practice was not followed perfectly is categorized as preventable. Learn more about our efforts to reduce these infections at BIDMC.

Falls Resulting in Injury

Patients may be prone to falling during a hospitalization. We report here all falls leading to harm (as defined above) and where an opportunity for prevention can be identified.

Acquired Pressure Ulcers/Soft Tissue Injury

Patients may be prone to developing pressure ulcers (bedsores) or other soft tissue injury during a hospitalization. We report here all such injuries meeting the definition of harm (as above) and where an opportunity for prevention can be identified. 

Preventable Harm in Association with Providing Medications

Included here are events relating to medication administration that meet the definition of preventable harm. 

Preventable Harm in Association with Surgery or Other Procedure

While acknowledging that there is inherent risk in any surgical procedure, we report here postoperative complications other than infection (such as bleeding) where an opportunity for prevention can be identified.

Other Preventable Harm in Association with Medical Care

We report here events that in the course of providing medical care, but not in relation to a specific operation, procedure, or medication. This would include harm events associated with some omission of care.

Disrespectful Communication

This category captures severe emotional harms resulting from communication, which can include: minimizing concerns, insensitivity, uncoordinated care, failure to disclose an adverse event, or failure to conduct appropriate advance care planning.

Failure to Maintain an Environment that Preserves Dignity

This category captures severe emotional harms from the environment which can include privacy concerns, prolonged unclean conditions, or visitor mismanagement.

Failure to Provide Appropriate Care After Death

This category captures severe emotional harms that occur to the family after, or with regard to death including misinformation about the autopsy process, mismanagement of the cadaver, or insensitivity regarding bereavement.

Failure to Care for Personal Possessions

This category captures loss of irreplaceable items such as family heirlooms or other items of significant worth.

Total Events