Learning from Actual & Near Miss Events

Transcription

1 POST-EVENT DEBRIEFING TOOL & INTERVIEW GUIDE Learning from Actual & Near Miss Events Using Debriefing Methodology Jeffrey Klenklen, MS, RN, NE-BC, CPHQ, CPHRM Senior Director of Patient Safety & Clinical Risk Management Clinical Operations Department Tenet Healthcare Patient & Resident Safety Issue The Director 19

2 POST-EVENT DEBRIEFING TOOL & INTERVIEW GUIDE Investigation and interviewing staff after an event it is important to follow guidelines that support a fair and accountable culture and staff reporting of events. The process needs to de-emphasize the staff fear of punishment and must feel beneficial to the staff members involved. 1 First, the interview needs to occur timely, but only after the staff member has had time to initially process the event and has had support of their immediate needs. The focus of the interview needs to be structured and focused on collection and clarification of events using a team style debriefing. Individual interview of staff may be appropriate when it is important to understand a individual staff members point of view or when you detect staff are not comfortable speaking in a team format. 2 Figure 1 (see pages 22 and 23) depicts the rapid post-event debriefing framework which I developed in our health system, and is used to debrief both a team and an individual after an event. The tool begins with critical information needed related to the event. It assists the interviewer in constructing a timeline of the event based on team debriefing or individual interview. The tool allows the investigator to document what immediate interventions the staff member or team took to correct the issue at the time of the event. These corrective actions may be temporary until a more system diagnosis can be made of the event and system opportunities in work flow can be addressed. The debriefing tool can be utilized by Risk Managers and Patient Safety Officers to lead the debriefing with the focus on timelines, structure, and creating a non-threatening environment. 2 The focus of data collection using the debriefing tool focuses on the following: Determining what happened with a focus on what and not on who. Do not assign responsibility of blame in the event Eliciting feedback from the team members involved or from the individual being interviewed asking staff not to use opinion based adverbs and description of root causes Making sure everyone on the team or the individual involved agree on the facts that have been collected by reading back the event timeline Asking the team or the individual being interviewed if they had a chance to repeat this event what would they have done differently 20 The Director Patient & Resident Safety Issue

3 The focus during the interview needs to be on what happened and less on who. It is important to rapidly assess whether the event represents human error, work around behavior due to system problems, or reckless behavior. Attempting to get from the group or the individual being interviewed lessons learned from this event in order to help construct immediate action steps that have been or need to be taken. It is important in this process to de-emphasize the staff member s performance in the event, and understand from them what systems surrounding the event either worked or did not work that led to the event. The focus during the interview needs to be on what happened and less on who. It is important to rapidly assess whether the event represents human error, work around behavior due to system problems, or reckless behavior. 3 It is also possible that no medical error can be detected from the briefing and the investigatory process stops. The debriefing tool serves as documentation of intense analysis of the event. The document should be stored in the rile management file and protected under appropriate state statutes as quality improvement information. The information gleaned from this individual interview also needs to be given to the team assembled to manage the event and disclosure; if the event meets sentinel event criteria or medical error has contributed to an adverse outcome to the patient. In the Long Term Care setting each organization can define when it would be appropriate to use the tool. Recognizing that most adverse events often contain system failures of opportunities to improve care systems potential indicators for completing a team debriefing could incude: Unanticipated fall with injury Unanticipated death or medical emergency Elopement of patient or resident Medication error causing patient or resident injury Allegation of abuse by patient or resident Other significant events as defined by organization. Understanding immediate corrective actions that need to be put in place to address system failures in a important use of the tool. As most adverse events in a healthcare setting encompass some level of medical error having the team together to discuss and debrief on the event gives them quick insight on how they might address or prevent the issue as a team going forward. References 1 Cullen, DJ., Bates, DW., Small, SD., Cooper, JB., Nemeskal, AR., and Leape, LL. (1995). The incident reporting system does not detect adverse drug events: A problem for quality improvement. Joint Commission Journal of Quality Improvement, 21, Turner, S., & Kurtz, W. (2008). Debriefing for patient safety. November/December. Retrieved from debriefing-fromopatient-safety.html on 9/02/13. 3 United Kingdom, National Patient Safety Agency (2003). The incident decision tree- Information and advice on use. Retrieved from professionals/quality-patient-safety/patient-safety-resources/advances-in-patient safety/vol4/meadows.pdf on 9/3/13 4 Agency for Healthcare Research and Quality professionals/quality-patient-safety/patientsafetyculture/nursinghome/indes.html Patient & Resident Safety Issue The Director 21

4 FIIGURE 1 POST-EVENT DEBRIEFING TOOL & INTERVIEW GUIDE This tool is designed to be used for the rapid investigation and review of significant occurrences The steps in completing the review are: TRIAGE Notification of occurrence via verbal or occurrence report to Risk Management. If the occurrence is determined to be significant, a rapid investigation is initiated. DEBRIEFING A meeting is quickly set up to discuss the occurrence (24-48 hours). The group membership includes the manager of the area where the occurrence happened, staff members involved and a facilitator from Patient Safety, Risk Management, Performance Improvement or Infection Control. DEBRIEFING SESSION INFORMATION Date of Debriefing: NAME OF PARTICIPANT TITLE DEPARTMENT NAME OF PARTICIPANT TITLE DEPARTMENT Team Leader PATIENT DEMOGRAPHICS/INFORMATION Patient Name: Room #: Account #: MRN: Date of Occurrence: Patient Age: Admitting Dx: Insurance: Attending Physician: Clinical Condition prior to event: q Good q Fair q Serious q Critical OCCURRENCE INFORMATION Date/Time of Event: Event Reporter: Event Location: Type of Event (Check One) q Anesthesia Related q Equipment Related q Slip/Fall q Medication Error q Surgical event q Procedure/Test Related q Other specify: 22 The Director Patient & Resident Safety Issue

5 DESCRIPTION OF EVENT (In words of reporter or person closest to the incident 2 to 3 sentences: What happened? Why did it happen? How did it happen?) NAME OF STAFF INVOLVED IN EVENT NAME TITLE DEPARTMENT NAME TITLE DEPARTMENT TIME-LINE MATRIX DATE/TIME ACTION ISSUES IMMEDIATE INTERVENTIONS TO PREVENT/MINIMIZE HARM TYPE OF BEHAVIOR IF MEDICAL ERROR INVOLVED q Human Error (inadvertent action: slip, lapse, mistake, unintentional) Console/Manage q At-Risk Behavior (Taken short cuts to save time, risk not recognized) Coach/Redesign q Reckless Behavior (Something which is a clear violation of their training) Performance Mgmt q No Medical Error detected- standard of care met FOLLOW-UP Referral: q CEO q CNO q CMO q Other, specify Next Step: q Disclose to Patient/Family: Medical error involved outside scope of risk/benefits of treatment q Trending q Intense Analysis q Taskforce q FMEA q RCA q None - Standard of Care Met Patient & Resident Safety Issue The Director 23