Comprehensive Analysis Method

Transcription

1 Incident Analysis Learning Program - Module Four Comprehensive Analysis Method Jan. 10, 2013

2 Welcome Ioana Popescu Sandi Kossey Erin Pollock Tina Cullimore

3 Learning Program M3 WHAT WAS LEARNED? WHAT CAN BE DONE? HOW AND WHY? WHAT HAPPENED?

4 Analysis Methods Canadian Incident Analysis Framework Systematic Systems Analysis Local framework Other (VA, NPSA)

5 Learning Objectives The knowledge elements include an understanding of the: Steps to take when undertaking a comprehensive analysis Benefits and limitations of different diagramming tools Various considerations when writing statements of findings The performance elements include the ability to: Describe the steps to create a timeline of the event Perform the main steps to analyze information to identify contributing factors and relationships

6 Agenda 3-parts Knowledge expert Practice leader Facilitated discussion

7 Introducing: WebEx Be prepared to use: - Raise Hand & Checkmark - Chat & Q&A - Pointer & Text 7 11-Jan-13 7

8 About You M2

9 Presentation Wayne Miller

10 Has this ever happened in one of your facilities? 3:45 pm Call from Nurse manager Patient has been given the wrong medication. Patient is unconscious and has been moved to the ICU and assessment is ongoing.

11 Individual Perspectives to Leading Practices Key Features of Incident Analysis Timely, Thorough Objective and Impartial (avoid conflicts of interest or perceived conflicts) Credible Interdisciplinary, Including Frontline, Patient/Family, and Nonregulated staff Practise / Preparing Who, When, and How is the analysis conducted in your organization Build Teams - Quality, IT, Health Records, Bio Med Run simulations Just and trusting culture encourages, supports, and expects the reporting of safety and learning events. M2

12 Page 39 Canadian Incident Analysis Framework

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14 Gather Information Caution Do not jump to solutions, conclusions, and assumptions. Caution The team will not understand the contributing factors related to the incident if they do not understand the circumstances surrounding the incident. Caution The facilitator must have systematic processes for identifying the gaps in information and for accurately addressing those gaps.

15 WHAT HAPPENED? Get a Game Plan Each Incident is different Gather Information Review the Incident (Occurrence) Report Review Additional information Create a Detailed Timeline Review Supporting Information

16 Review the Incident Report & Additional information Triggers for a comprehensive analysis Incident report is based on initial understanding Others Review the health record Conduct interviews Visit the location where the incident occurred Secure items OR look at similar items/devices to help build that understanding

17 Create a Detailed Timeline Example (p.104)

18 Review Supporting Information Includes: Review of Policies and Procedures Look at previously reported similar incidents Environmental Scan Literature Search Policies and Practices in leading organizations Consultation with colleagues or experts in the field.

19 HOW AND WHY IT HAPPENED? Analyze information to identify contributing factors and relationships Uses systems theory and human factors Uses diagramming Summarizes findings

20 Analyze Information Build on understanding by asking questions to determine contributing factors and relationships of factors to the event. Appendix G, Page 89, Guiding Questions Allows lens to focus on system issues which may have contributed to the event rather than focus on the person What was this influenced by? What else affected the circumstances?

21 Use Systems Theory and Human Factors Systems Theory Focuses on an assessment of the individual s action within the context of the circumstances at the time, NOT on the individual alone. Human Factors Interaction between the human and the system

22 Use Diagramming Identify and understand inter-relationships between and among contributing factors Provides a map which, when used correctly, helps the team identify the route which was taken and why it was taken. Shifts the focus from the person to the system in which the person works.

23 Diagramming Ishikawa Diagram

24 Diagramming Tree Diagram

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26 Constellation Diagramming 5 steps Step 1: Describe the incident Step 2: Identify potential contributing factors Step 3: Define inter-relationships between and among potential contributing factors. Step 4: Identify the findings Step 5: Confirm the findings with the team

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28 Appendix G (p. 89) Guiding Questions Example

29 Summarize Findings Statements of findings Describe the relationships between the contributing factors and the incident and/or outcome. Three categories of findings: Factors that if corrected would likely have prevented the incident or mitigated the harm. Factors that if corrected, would NOT have prevented the incident or mitigated the harm, but are important for patient/staff safety or safe patient care in general Mitigating factors factors that didn t allow the incident to have more serious consequences and represent solid safeguards that should be kept in place

30 Statement of Findings Example The use of gravity intravenous infusion sets in the Emergency Department increased the likelihood that an intravenous narcotics infusion would be infused at a higher than intended rate when the patient changed his position on the stretcher

31 Confirm Findings Team should agree on the findings before developing recommended actions Work through disagreements to achieve consensus If key individuals who were involved in the event were not part of the analysis team, ask for their feedback on the findings. Include a Back-Checking Step

32 Ultimate Goal To WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER

33 WHAT WAS LEARNED? Healthcare providers work very hard to provide safe care in the best way they know how. Let s not ask them to do this risky work without a net

34 Real-life Experience Dr. Chris Hayes

35 Incident Analysis Framework: Real-life Experience Module 4: Comprehensive analysis method January 10, 2013

36 What is critical incident (ie. a severe harmful patient safety incident) Any unintended event that occurs when a patient receives treatment in the hospital, that results in death, or serious disability, injury or harm to the patient, and does not result primarily from the patients' underlying medical condition or from a known risk inherent in providing the treatment

37 What is critical incident (ie. a severe harmful patient safety incident) Not Any factored unintended into event the definition that occurs at St. when a Michael s patient receives treatment in the hospital, perspective of patient outcome is considered that results in death, or serious disability, first.harm feels like harm!! injury or harm to the patient, and assumes inherent risks are fixed with no potential does not in result learning primarily or reducing eg from the patients' CLI data underlying supports medical inherent condition risk of or death from d/t a known adverse risk inherent events in providing = 1/116 the treatment

38 An example Patient admitted to the ICU following a large stroke. At approximately midnight the patient began having generalized seizures. She paged the resident on call. The resident came and asked for some Ativan. As the resident was giving the Ativan he asked the nurse to quickly get some Dilantin (phenytoin). The nurse left the bedside to prepare the medication in an IV minibag, returned to the bedside and began to hang the drug. Meanwhile the Ativan had stopped the seizure and the resident returned to his call room. 20 minutes later the patient s blood pressure rose to 230 over 120 mmhg. The patient began complaining of chest pain and was visibly short of breath. The nurse paged the resident to the bedside STAT. The resident on arrival asked for some IV metoprolol. He gave 20mg in total with little effect on the blood pressure.

39 An example Eventually the patient was stabilized but had suffered a large heart attack and now had significant congestive heart failure. Later that evening the resident noticed a vial of phenylephrine at the patient s bedside. He showed this to the nurse who became immediately very upset and was later sent home. The Charge Nurse reported the incident later that evening, the family was informed of the incident and received an apology Risk Management & QI team reviewed the incident details and decided that a comprehensive review be conducted

40 So it s an adverse event The next phase is to analyze the event in order to know: What happened How and why it happened What can be done to reduce the likelihood of recurrence and make care safer What was learned

41 Conducting the analysis

42 Conducting the analysis Date / Time Information item Comment / Source Jan 1, 12 22:45 Patient admitted with stroke Patient record Jan 2, 12 00:20 23:35 Patient develops GTC seizure Nurses notes, confirmed by nurse interview 23:40 Resident assessed, gave Ativan and verbally ordered Dilantin 1g over 20 min 23:55 Nurse finished preparing, hung and administered Dilantin Patient blood pressure noted at 230/120, requring more oxygen Patient record, confirmed by resident interview Patient record, confirmed by nurse interview Patient record 00:50 Patient s BP resolved but requiring more oxygen Patient record ~01:20 Bottle of phenylephrine discovered at bedside Interview with resident ~01:50 Bedside nurse relieved of duty and went home Interview with charge nurse 10:30 Echo done and shows Grade 3 LV Patient record

43 Conducting the analysis

44 Conducting the analysis Verbal order given Acute issue, middle of night Double-check policy does not include anticonvulsants Sound-alike, look alike drugs stored together Nurse had to leave bedside to prepare med Patient suffers large MI and CHF following wrong drug administration

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46 Swiss Cheese model Medication organization Manufacturer Hazards Sound-alike look-alike drug Purchasing Losses CHF/MI RN/MD Double-check

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48 What did we do?

49 What did we do?

50 Recommendations / Actions Introduced TallMan lettering Removed multi-drug bins and reorganized med cabinets Moved phenytoin under D for dilantin Did the same for all other ICUs, then all wards Met with Clinical Services Committee and Pharmacy re purchasing of sound-alike, lookalike drugs Discussed the problem and the solution openly

51 Recommendations / Actions

52 Summary Incident analysis is a standard process to learn what, why and how an patient safety incident occurred An interprofessional, open and just approach fosters greater learning Requires gathering of material facts and interviews of those involved Requires open exploration of all contributing system factors Done right leads to effective recommendations and improvement in patient safety

53 Case Study Virtual Group Exercise

54 Breakout Session Most participants will move to breakout rooms Some participants will stay in the main room Those prompted: click YES to both pop-up screens to move

55 Small Group Discussion 0 Experience with comprehensive analysis 10 - Share your organization s comprehensive analysis process (what works well and what can be improved) - Point out the differences with the comprehensive method presented (4 objectives, steps, tools) - What would you need to do tomorrow to make the comprehensive analysis more effective

56 Large Group De-Briefing

57 Wrap-up

58 Next Steps End of session evaluation certificate of attendance Follow up survey we learn from you Incident Analysis Learning Program Concise analysis January 31, 2013 Multi-incident analysis February 21, 2013 Recommendations management March 7, 2013 Follow-through and share what was learned March 28, 2013

59 Resource slide Learning Program previous modules: rogram/pages/session-recordings-and-documents.aspx HQCA s Systematic Systems Analysis ews%20final%20june% pdf Incident Analysis Tools ysis/pages/tools.aspx

60 Mulţumesc Thank You