Letter to the Editor| Volume 205, ISSUE 4, e12-e13, October 2011

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# The Weill Cornell Patient Safety Program Study: feedback from patient safety advocates in medicine, law, and root cause analysis

Published:June 13, 2011
To the Editors:
We read, with great interest, the article by Grunebaum et al “Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.”
• Grunebaum A.
• Chervenak F.
• Skupski D.
Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.
As longstanding patient safety advocates, we applaud Weill Cornell's tremendous investment of time, effort, and money into this program.
What were the criteria used to classify an incident as a “sentinel event” in the study? Although the authors note The Joint Commission's definition of a sentinel event, their own was much more narrowly defined (“at our institution, sentinel events included maternal deaths, and serious newborn injuries, including birth asphyxia and hypoxic ischemic encephalopathy”), accounting for only the rarest and most extreme outcomes. Because sentinel events are the “tip of the iceberg,” a decrease in the number of sentinel events, small to begin with, may not indicate an appreciable improvement in the overall safety or quality of patient care.
How might a broader definition of “sentinel event” to include nonfatal adverse outcomes and near misses have changed the study results and implications? The program's impact might be more widely celebrated if results showed a decrease in often preventable adverse obstetric outcomes, such as unnecessary major surgical procedures (Weill Cornell has an extraordinarily high 40% cesarean section rate
Choices in Childbirth with statistics from the New York State Department of Health New York City hospitals cesarean section rates 2000-2008.
), severe perineal tears, postpartum hemorrhage, neonatal ICU admissions, and postpartum posttraumatic stress disorder.
How did the criteria for identifying sentinel events change at the hospital over the study period? Despite systems to track errors, adverse events, and near misses, internal and external underreporting remains a significant problem.
• Drake-Land B.
CMS never events: exploring the connection between tracking near misses, organizational learning and the potential to reduce the occurrence of never events in healthcare organizations.
It is curious that 2008, the first year of the CMS “Never Event” policy limiting the ability of hospitals to bill for serious reportable events, was the same year that Weill Cornell's sentinel event count dropped to zero.
What organizational system-level changes have occurred to prevent the recurrence of adverse outcomes? Most adverse events are the end result of a chain of chronic, repeatable, low-consequence deficiencies. Proactive, statistically rigorous approaches like failure modes and effects analysis and root cause analysis, would help determine the relevance, reliability, sustainability, and cost-effectiveness of the safety interventions.
Are there data on the number of and costs to defend nonlawsuit, noncatastrophic claims, and the frequency of error reporting and disclosure? A comprehensive analysis of total liability claims and costs associated with an open disclosure-with-offer program at the University of Michigan
• Kachalia A.
• Kaufman S.
• Boothman J.D.
• et al.
Liability claims and costs before and after implementation of a Medical Error Disclosure Program.
demonstrated compensation payment reduction without compromising ethics, transparency, or safety culture.

## References

• Grunebaum A.
• Chervenak F.
• Skupski D.
Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.
Am J Obstet Gynecol. 2011; 204: 97-105
1. Choices in Childbirth with statistics from the New York State Department of Health.
(Accessed July 13, 2011)
• Drake-Land B.
CMS never events: exploring the connection between tracking near misses, organizational learning and the potential to reduce the occurrence of never events in healthcare organizations.
RL Solutions, Toronto2008
• Kachalia A.
• Kaufman S.
• Boothman J.D.
• et al.
Liability claims and costs before and after implementation of a Medical Error Disclosure Program.
Ann Int Med. 2010; 153: 213-221

Our objective was to describe a comprehensive obstetric patient safety program and its effect on reducing compensation payments and sentinel adverse events. From 2003 to 2009, we implemented a comprehensive obstetric patient safety program at our institution with multiple integrated components. To evaluate its effect on compensation payments and sentinel events, we gathered data on compensation payments and sentinel events retrospectively from 2003, when the program was initiated, through 2009. Average yearly compensation payments decreased from $27,591,610 between 2003-2006 to$2,550,136 between 2007-2009, sentinel events decreased from 5 in 2000 to none in 2008 and 2009.