Completed by: Patient Safety Committee Date Completed: Ocber 31, 2017 Methodology: Information utilized complete this Patient Safety Hazard Assessment included availa patterns/trends, high risk, prom prone issues, trends in the community and other indicars. Probability and Severity of hazards patient safety are assessed against the following risk matrix: Matrix Green = Low, Yellow = Medium, Red = High Probability Certain 5 5 10 15 20 25 Likely 4 4 8 12 16 20 Possi - 3 3 6 9 12 15 Unlikely - 2 2 4 6 8 10 Rare - 1 1 2 3 4 5 Negligi 1 Minor 2 Moderate 3 Serious 4 Catastrophic - 5 Severity Matrix guide severity of risk level Severity of incident Injury / Illness Patient Experience Catastrophic Death or Totally major and unsatisfacry permanent patient outcome incapacity or disability Serious Moderate Minor Negligi Major injuries or long-term incapacity or disability Significant injury or ill health; medical intervention necessary; some temporary incapacity Minor injury or ill health first aid or selftreatment no incapacity Injury or illness not requiring intervention Patient outcome or experience significantly below reasona expectation across the board Patient outcome or experience below reasona expectation in one or more areas Patient experience temporarily unsatisfacry rapidly resolved Single resolva prom in patient experience / project / targets / objectives Failure of critical system project / targets / objectives Partial failure of critical systems, projects, objectives or target achievement Resolva prom with critical system, project, target or objectives achievement Partial failure of important system, project, target or objective achievement Failure of peripheral system / project / target or objective achievement Resolva prom with important system, project, target or objective achievement Resolva prom with peripheral system, objective or project Complaints / Claims Multiple claims or single major claim Above excess claim, multiple justified complaints Justified complaint involving the lack of appropriate care or below the excess claim Justified complaint peripheral clinical care (e.g., car parking / access) Low value claim handled by an ex gratia payment Financial Loss Over $ 1,000,000 $50,000 - $1,000,000 $5,000 - $50,000 $500 - $5,000 Adverse Publicity Nationwide multimedia coverage Extensive local coverage and widespread ADHS / MCDPH coverage Coverage throughout the organization and / or some public coverage Coverage limited elements within the organization $0 - $500 Awareness limited individuals within the organization Page 1of 10
Matrix guide probability of occurrence Frequency 1 2 3 4 5 Rare Unlikely Possi Likely Certain How often might it happen (per procedure / episode or within a specified timeframe)? Can t believe that it will ever happen or recur Do not expect it happen or recur but it is possi Might happen or recur occasionally Will probably happen or recur but it is not a persistent issue Will undoubtedly happen or recur, possibly frequently Priorities were identified through prospective and retrospective review. Generally, priorities are those items scoring a high on the probability / severity risk matrix. Although all items have not been identified as priorities, they will still be considered as potential opportunities for improvement, particularly those in which the Current is 3 (poor). For healthcare-associated infections, see the Infection Prevention & Control Assessment Priorities Identified for 2018 PRIORITY for 2018 Medications Medication events incorrect drug Medication event incorrect time Medication events incorrect dose Medication events - opioids Medication events - anticoagulants Medication events - insulin Communication Patient information during Epic downtime Falls Falls while ambulating Falls while ileting Lab Mislabeled / Unlabeled specimens Leadership and Regulary Elopement / AMA / LWOT Fire Evacuation Mitigation / Action Plan Include Medication Safety in Patient Safety Committee Meetings Form Workgroup develop action plans mitigate medication events Conduct RCA Develop and implement action plan(s) Continue Falls Workgroup action plan Drill down on specimen data identify trends Present specimen event data at Patient Safety Committee Continue workgroup/action plan as appropriate Emergency Services monir ED door doc times Consider entrance / exit / nurse station locations during the Care Reimagined processes Identify high risk areas for fire evacuation Encourage ta-p / practice exercises for patient evacuation in the event of a fire Page 2of 10
Patient Identification wrong patient errors when administering medications? Certain Likely Possi Unlikely Rare wrong patient errors when administering blood or blood components? Inpatient: critical care Inpatient: noncritical care 1 3 1 3 x x Other x 3 3 1 9 wrong patient errors when collecting blood and other specimens? What is the risk wrong patient errors when performing surgery, treatments or procedures? Communication critical test/diagnostic results not being communicated correctly? critical test/diagnostic results not being communicated timely? 3 3 1 9 Page 3of 10
misinterpreting medical orders and documentation due abbreviations, acronyms, symbols and dose designation? Certain Likely Possi Unlikely Rare x not having full information during nursing handoffs? not having full information during physician handoffs? not having full information critical patient care during Epic downtime? misinterpretation due verbal orders? Medications a medication error due look-alike/soundalike medications (incorrect drug)? 3 2 2 6 3 2 2 6 4 4 2 16 x 3 3 2 9 4 3 2 12 Page 4of 10
a medication error due unlabeled or mislabeled medications? Certain Likely Possi Unlikely Rare harm due unreconciled medications? an high-risk medications (anticoagulant; insulin; opioid)? an timing of medication administration? a medication due wrong dosage of medication? Perioperative / Procedures wrong site surgery / procedure? 3 3 2 9 4 2 2 8 4 3 2 12 4 3 2 12 4 4 2 16 2 4 1 8 Page 5of 10
the wrong surgery / procedure being performed? Certain Likely Possi Unlikely Rare Page 6of 10 a fire related surgery or procedure? an anesthesia an sedation? an intraoperative event (nerve compression / malignant hyperthermia / hemorrhage)? an iatrogenic complication (hypotension, pneumothorax, etc.)? Mortality an unanticipated death or major permanent injury? 2 4 1 8 1 2 1 2 2 4 1 8 3 3 2 9 3 3 2 9 3 3 1 9 1 4 1 4
Page 7of 10 Certain Likely Possi Unlikely Rare Restraint / Seclusion harm related the use of restraints or seclusion? Falls patient harm resulting from a fall? Pressure Ulcers patient harm due healthcare-associated pressure ulcers? Lab Blood / Blood Products a transfusion reaction after blood or blood component administration? inappropriate blood usage? discrepant pathology reports? 3 2 1 6 4 3 12 3 2 1 6 1 4 1 4 2 2 2 4
mislabeled / unlabeled specimen errors? Page 8of 10 Certain Likely Possi Unlikely Rare Self Harm patient suicide? patient self-inflicted harm? Medical Devices and Equipment an the misuse of medical devices and equipment? an untimely preventative maintenance? patient harm due inadequate levels of back-up equipment? Obstetrics an early elective delivery? 4 3 3 12 2 4 1 8 3 3 2 9 3 2 1 6 2 2 1 4 2 1 1 2 1 2 1 2
Page 9of 10 Certain Likely Possi Unlikely Rare an obstetrical trauma / complication (uterine rupture, 3 rd or 4 th degree laceration, fetal death)? Leadership and Regulary retaliation for reporting errors, mistakes and near misses? inadequate risk mitigation efforts related the lack of proactive and retroactive review, investigation, and action items for highrisk/prom prone processes and Serious Reporta Events? elopement / AMA / LWOT? harm related nurse staffing? harm related physician staffing? 3 3 9 3 3 2 9 2 3 2 6 4 3 2 12 2 2 1 4
Certain Likely Possi Unlikely Rare harm related patient evacuation in the event of a fire? 2 5 1 10 Page 10of 10