The Virginia Mason Heart Institute Quality Committee implemented a standardized process for reviewing adverse events to decrease the time between when events occurred and when they were reviewed. They held a two-day workshop where they developed a one-page review form and process to classify events and escalate reviews if needed. After implementing the new process, the average time to review decreased significantly from over 50 days to under 10 days, allowing for more timely quality improvement projects.

1. IMPROVING REVIEW OF ADVERSE EVENTS
IN CARDIOVASCULAR CARE
Drew Baldwin, MD; Cindy Jo Allen, MBA, RN; Travis Gerrard, MD; Roxanne Juel, RN, John Campos, MA
Virginia Mason Medical Center, Seattle, WA
BACKGROUND
METHODS
RESULTS
CONCLUSIONS
The Virginia Mason Heart Institute Quality Committee reviews
cardiology and CT surgery adverse events. Typically, reviews took
place several days, weeks, or even months after adverse events.
We hypothesized that a standardized method for reviewing adverse
events could decrease the length of time from adverse event
occurrence to adverse event review. We felt that this was an
important goal, as prompt review of adverse events could help us to
develop effective, timely quality improvement projects.
The Quality Committee held a 2 day Lean kaizen workshop to
improve the method for reviewing adverse events. Representatives
from cardiology, CT surgery, and the patient safety department
participated. A patient advocate also participated. We defined
adverse events as deaths, procedural complications, and
unplanned 30-day readmissions. We collected adverse event data
for 3 months before the workshop and for 3 months after the
workshop. We recorded the date and time the adverse event
occurred, the date and time the adverse event was reviewed, the
type of adverse event, the probable cause of the adverse event, the
severity of the adverse event, and the preventability of the adverse
event. We assessed the results using the unpaired t test method.
• Using a standardized method for reviewing adverse events was
associated with a significant decrease in the time from adverse
event occurrence to adverse event review.
• The greatest gains occurred because the initial review of adverse
events was performed daily by the Quality Committee, rather than
at the end of the month at a Morbidity and Mortality Conference.
We found that with the standardized process, more adverse events
were being recognized and reviewed.
• This project also contributed to improvements in the structure of the
Heart Institute Morbidity, Mortality, and Improvement Conference.
• We anticipate that this standardized process for prompt review of
adverse events will lead to improvements in the timeliness and
effectiveness of quality improvement projects.
• During the kaizen workshop, the team developed a new
standardized process for reviewing adverse events, which
empowered all members of the Quality Committee to review
events using a standardized review form. The one-page form
included criteria for classifying adverse events according to type,
cause, severity, and preventability. The form included guidelines
for escalating the review if necessary, with criteria for notifying
the patient safety office and performing a root cause analysis.
• With the new process, at least one member of the Quality
Committee was expected to review the adverse event within 72
hours of being notified of the event. The findings of the Quality
Committee were discussed at a monthly Morbidity, Mortality, and
Improvement conference, with focus on preventable events.
• After implementation of the standardized process, the mean
length of time from adverse event occurrence to adverse event
review decreased from 51.8 days (range 11.4 days – 108.6 days,
N = 46 events) to 9.8 days (range 0.13 days – 94.4 days, N = 63
events; p < 0.0001).
Figure 1. Quality improvement cycle Figure 3. Results
Figure 2. Adverse event review worksheet
REFERENCES
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RCA2: Improving root cause analyses and actions to prevent
harm. National Patient Safety Foundation 2015. Retrieved May 7, 2016
from www.npsf.org/?page=RCA2.
Sacks GD, et al. Morbidity and mortality conference 2.0. Ann Surg
2015;262:228-9.
Contact: drew.baldwin@virginiamason.org