Patient Safety Event Review Process & Tools

Patient Safety Event Review Process & Tools

Event Occurs Patient Safety Event Review Process Immediate actions are taken to care for the patient, make the situation safer for others and sequester equipment/products Entered into Reporting System (VOICE) Opened for investigation by Patient Safety & Unit Manager Patient Safety reviews the events daily for events needing scoring committee review. May require gathering additional information during this phase. Patient Safety Prepares SBAR for potential Serious Safety Events (SSEs) Event Response Prioritization tool should direct the type of response/review that will be used SSE Scoring Committee sets SEC harm scale and response Could be RCA, or ACA Each event should have one strong, or two intermediate actions in addition to any other identified weaker actions. SSE Committee is comprised of leadership and is actively involved in the RCA and actions by supporting the process, approving and periodically reviewing the status of actions, understanding what a thorough assessment report should include, and acting when reviews do not meet minimum requirements. Owners are identified for every action item and responsible for implementation and measurement. Patient Safety follows-up on action items for status updates. Event Response/Review Conducted SSE Committee Reviews and endorses (or not) the action plan Implementation, Measurement & Feedback

Severity Event Response Prioritization Severity and Frequency Evaluation Matrix to Prioritize Response Are there system issues present? Is this a patient safety concern? If yes: 1. Determine priority based on severity and frequency 2. Determine appropriate response based on matrix 3. Determine if event meets TJC Sentinel Event definition Catastrophic Major Moderate Minor Frequency Historical Event Occurrence Consider Rare Less than one event each year Frequency should be specific: by service, by location, by equipment or med type, by procedure type. If we Unlikely One event per year, annually see trends in event-type throughout the institution, consider aggregation. Possible 3-4 times per year, quarterly Likely Monthly or every other month Almost Certain Weekly or daily Severity Actual Harm Intervention SSE Range Minor No injury or minimal, temporary injury No intervention or minimal intervention NME or PSE 3, 4 + Moderate Major (Serious) Catastrophic Rare Unlikely Possible Likely Almost Certain Moderate level of harm that is temporary or minor permanent Serious Harm, Severe temporary or moderate permanent harm resulting in long term disability Death-unexpected and not related to underlying condition (or hastened), severe permanent harm 1 3 Priority Extreme High Moderate Low Meets TJC sentinel event definition? Requires additional monitoring or testing, minimal surgical intervention (sutures) Major interventions include escalation in level of care, surgical interventions, and prolonged length of stay Requires heroic life-saving measures unrelated to patient s expected medical course, amputation 2 PSE 1, 2 or SSE 5 SSE 3, 4 SSE 1, 2 Response * RCA 1 : Multidisciplinary review, SSE Committee review. Action plan within 45 business days. Local Review with required follow up: Local review and action plan sent to SSE Committee for review of action plan within 60 business days. Aggregate and/or Committee: Consider for aggregation. If appropriate committee exists, send for review. Findings entered into VOICE or sent to SSE Committee as directed. Local Review, Optional Follow Up: Findings entered into VOICE. S Sentinel Events: Regardless of response-type above action plans must be developed within 45 business days. *If concerns about individual performance are discovered, consider sending for case review or to HR for performance review. 1 May be facilitated by an existing institutional team, if deemed more appropriate by the SSE Scoring Committee. + Potential: Consider near miss or precursor with potential for catastrophic harm as catastrophic rating at the discretion of SSE Scoring Committee members

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Debrief Form Content Situation: Description of event, approximately one or two sentences. Background: Provide some background information related to this problem or situation. Include pertinent medical information. What is the frequency of occurrence? Assessment: What is your assessment of the current situation or problem? Focus on system processes positive and/or negatives; what went well/what could have gone better. Consider the following as potentially contributing to the event: Teamwork Availability of Information Technology Equipment/Supplies Staffing Environment Communication Processes Recommendation(s): Consider immediate interventions to prevent /minimize harm. Additional Considerations: Notify your chain of command? Is there a need to secure equipment, supplies, medical devices, and/or medication? Any patient or family ongoing support needed? Do we need to involve Social Services, Pastoral Care or Patient Liaison? Care for the caregiver? Is there a need for disclosure?

What happened? Root Cause Analysis Process 1-2 sentences include impact to the patient and/or Flow diagram Identify RCA Team Including executive sponsor & RCA lead Document/ Record Review RCA Lead 1 st Meeting: Identify Interview Plan 2 nd Meeting: Identify Contributing Factors Identify interviewees Identify triggering questions Schedule future meeting Build from the initial flow diagram Contributing Factors from Initial Interviews 14 days or less 3 rd Meeting: Contributing Factors & Countermeasure s 4 th Meeting Cont. Contributing Factors Identify Countermeasures Identify metric(s) to gauge success Final Edit of Report Discuss process owners feedback Prepare leadership briefing

Action Hierarchy Less memory or reliance on individual performance More memory and reliance on individual performance Stronger Actions Intermediate Actions Weaker Actions Architectural/physical plant changes New devices with usability testing before purchasing Engineering control or interlock (forcing functions) Simplify the process and remove unnecessary steps Standardize equipment or process Tangible involvement and action by leadership in support of patient safety Redundancy Increase in staffing/decrease in workload Software enhancements/modifications Education using simulation-based learning with a competency assessment completed on a recurring basis Eliminate/reduce distractions (sterile medical environment) Checklist/cognitive aid Eliminate look and sound-alikes Repeat-back/Read-back Enhanced documentation/communication Double checks Warnings and labels New procedure/memorandum/policy Traditional training Additional study/analysis 9

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Munson Medical Center Patient Safety Team 11

Foundations of Safety Culture Trainers Site Coord 1 2 3 MMC Cadillac Grayling POMH Kalkaska Charlevoix Manistee Rachel Stein Lindsey Mack Amanda Rommell Jessica Blazok Joanna Benchley Kathryn Bandfield- Keough Jeremy Carlson Theresa Schepers Roberta Bellinger Dawn Cupp Susan Kilbourn Nancy Goodyear Julie Banktson Ann Holmes Kris Thomas Judy Spoor Kim Babcock Christine Bissonette Connie Farrier Allyssa Brooks Mike Aenis Allen Stout Grace Berry Diane Valley Gina Hodges Michelle Ruhser Mellissa (Missy) Hilliard- John 4 Kassidy Fleis Ben Elliott Heather Kage Alexi (Alex) Callaway 5 John Bolde Theresa Feldhauser Pam Walsh Delaney Bachman 6 7 8 9 10 Melanie Engels Claudia Orth Frank Mancuso Diane Barton Julie Botsford 11 Penny Hawkins 12 13 14 15 16 17 Wendy Hunt Tiffany Fortin Katherine Parrish Kathy Sahs Kristen Horton Cathy Munoz Beth Workman Grover Raymond Jennifer Fuhrman Rebecca Reda Jessica Fultz Amanda Trudgeon Michael Hodnett Tonimaree Verville John Charette Kristen King 12