Incident Reporting and Investigations Mary Bolbrock, RN MSN Ann Marie McDonald, RN EdD
Objectives To serve as a training tool for identification of incidents and conduction of incident investigations To identify the facts associated with an incident To outline the steps of a root cause analysis(rca) investigation To define the incident analysis process to reduce risk, prevent reoccurrence and improve quality
INCIDENT REPORTING REGULATIONS: CMS 482.21 Condition of Participation: Quality assessment and improvement program The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations. Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.
WHAT IMMEDIATE ACTIONS SHOULD BE TAKEN IN RESPONSE TO AN INCIDENT? Has the patient been assessed for injury? Has a patient physical examination been completed? Was prompt medical care and treatment administered? Was the area secured and made safe? Was any equipment secured and removed from service? Was any alleged perpetrators separated from a victim? Was an incident report completed? Was incident facts documented in the EMR? Was patient and/or family notification completed?
INCIDENT DOCUMENTATION DO S AND DON'TS
Incident Investigations
WHAT IS THE PURPOSE OF AN RCA INVESTIGATION? Establish the full facts Establish sequence of events that led to the event Determine what, how and why it happened. Identify who was involved Determine the impact to patient and/or staff Identify unsafe acts/conditions/any contributory factors Initiate short term actions to eliminate the direct cause Establish a long term plan to prevent reoccurrence
Who? What? When? Where? Why? How? INCIDENT INVESTIGATION STEPS
WHO? WHO was involved in the incident? WHO responded to the incident? WHO secured the incident scene? WHO was injured in the incident? WHO was working with the patient at the time of incident? WHO discussed the incident with the patient/family? WHO will be responsible for investigating this incident? WHO needs to attend the RCA?
WHAT? WHAT was the patient outcome? WHAT was observed-what did the witnesses see? WHAT happened-before the incident/after the incident? WHATaction was taken when the incident was discovered? WHAT was the patient s status at the time of the incident? WHAT was staff member s performance at time of incident? WHAThospital policies were associated with this incident? WHATcorrective actions are needed?
WHEN? WHEN did the incident happen-date and time? WHEN was it reported? WHEN was the supervisor informed? WHEN was the physician notified? WHEN was it reported to risk management? WHEN was incident discussed with patient /family? WHEN has this type of incident occurred before? WHEN was the incident reported to regulatory agency?
WHERE? WHERE did the incident occur? WHERE was the patient at the time of incident? WHERE is the patient now? WHERE were the staff at the time of incident? WHERE were the witnesses when incident occurred? WHERE is the evidence relating to the incident secured? WHERE is the incident report?
WHY? WHY did the incident occur? WHY did the problem occur? WHY was the information not communicated? WHY did the system fail? WHY was the patient not monitored? WHY did staff not follow policy? WHY was it not reported sooner?
THE 5 WHYS TO DETERMINE A ROOT CAUSE The 5 Whys involve asking Why the problem happened and then repeatedly asking the question Why to help identify the root causes of the problem and to determine the relationship between different root causes of the problem. 5 WHYs Why, Why, Why, Why, Why
Problem Statement: Wrong patient transferred to radiology What are the 5 Whys associated with this event? Why? Why? Why? Why? Why?
HOW? HOW did it happen-was this incident avoidable? HOW many people were involved in the incident? HOW was this incident reported to the patient/family? HOW did staff behave, react and respond to the incident? HOW was staffing when the incident occurred? HOW has the incident been corrected? HOW will the incident be followed up? HOW many other patients are at risk for this type of incident?
RCA INVESTIGATION PREPARATION PROCESS Complete patient medical record review. Obtain and review written statements. Conduct staff interviews with those involved in the incident. Obtain any pertinent paper records-ex. Observation log. Review any video surveillance associated with incident. Complete literature review, obtain national guidelines, evidence based practice references. Obtain and review any P&P related to the incident. Obtain and review assignment sheets/staffing schedules.
RCA INVESTIGATION INFORMATION COLLECTION Appropriate department gathers pertinent information related to incident. Investigation information is submitted to Risk Management in preparation for RCA investigation. RCA meeting will be scheduled in accordance with the nature of the incident. Literature review will be completed. Note: RCA investigation information should not be placed in an e-mail message to reduce the risk of this information becoming discoverable.
ROOT CAUSE ANALYSIS (RCA) REVIEW PROCESS RCA meeting with Core Team and responsible parties RCA group review of incident investigation material Literature review correlation to incident RCA group determination of root causes associated with the incident Corrective actions are defined Performance improvement monitoring measures established RCA completion with submission to regulatory agency, if required
RCA FOLLOW-UP MONITORING Monitoring of corrective actions is necessary to prevent reoccurrence and to determine if corrective actions are effective.
Questions?
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