57 Improving the Safety and Quality of Inter-Hospital Transfer for Nontraumatic Intracerebral and Subarachnoid Hemorrhage

Abstract

Taxonomy Development and Testing: The taxonomy was empirically developed on w600 AEs identified in a companion project that used the NCC MERP Index to describe severity. Our iterative process balanced parsimony with specificity describing both harm and non-harm events. We collapsed rare events into higher level sub-categorizations and added modifiers to provide further description. Safety and quality experts at 5 medical centers trained on use of the taxonomy on a conference call. To estimate reliability, collaborators independently reviewed 25 AE scenarios. Inter-rater reliability was assessed using the Fleiss kappa statistic for multiple raters.Results: The 50 most-cited articles (out of 165) and the taxonomies from 10 major patient safety organizations yielded 2 that included descriptions of harm: The Joint Commission's Patient Safety Event Taxonomy and the taxonomy from Adventist Health System. We used the latter as starting point, defining 7 categories and 51 subcategories. We added up to 3 "modifiers" per event (from a total of 46 modifiers available) to better describe events. Twenty-one distinct category-subcategory dyads were represented in the 25 test scenarios. There was complete agreement between reviewers in 20/25 scenarios. Inter-rater reliability was excellent for both overall-category scoring (k ¼ 81%) as well as for dyad scoring (k ¼ 79%).Conclusions: We developed a taxonomy of adverse events and non-harm events for the ED modified from an existing framework. Use of the tool with minimal training yielded excellent performance with high interrater reliability. We will perform additional reliability testing to cover all possible dyads and once validated, plan to use this taxonomy in further work related to adverse event detection in the ED.