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Improving Pa-ent Safety through Incident Repor-ng and Learning in
Health Care
Michelle Hanbidge MHSc Candidate – Clinical Engineering
September 20, 2013
Ra-onale
• Health care incident learning processes have the poten7al to minimize preventable errors and pa7ent deaths
• Currently experiencing mixed success • Li?le guidance exists for decision makers on how to successfully learn from incidents
January 10, 2014 2
Objec-ves 1. Describe areas for improvement in health care
incident learning processes 2. Explore exis7ng barriers and end‐user needs 3. Iden7fy strategies that avia7on and nuclear power
have implemented to achieve their successes 4. Evaluate preliminary strategies based on health care
stakeholder feedback 5. Propose strategies for the development of successful
incident learning systems in health care
January 10, 2014 3
WHO Recommenda-ons Quality Descrip-on
Non‐Puni-ve Reporters are free from fear of retalia7on against themselves or others as a result of repor7ng
Confiden-al Pa7ent, reporter, and ins7tu7on iden77es are never revealed
Independent Repor7ng system is independent of any authority with the power to punish the reporter or organiza7on
Expert Analysis Reports are evaluated by experts who understand the clinical circumstances and are trained to recognize underlying systems causes
Timely Reports are analyzed promptly and recommenda7ons are rapidly disseminated to those who need to know
Systems‐Oriented Recommenda7ons focus on changes in systems, processes, or products, rather than on individuals
Responsive The agency that receives reports is capable of dissemina7ng recommenda7ons and the par7cipa7ng organiza7ons consent to implemen7ng recommenda7ons when possible
January 10, 2014 4
The World Health Organiza7on, "WHO DraU Guidelines for Adverse Event Repor7ng and Learning Systems," WHO Document Produc7on Services, Geneva, 2005.
WHO Recommenda-ons Quality Health Care* Avia-on (ASRS) Nuclear Power
(IAEA/NEA)
Non‐Puni-ve X Confiden-al Varies X Independent Varies X
Expert Analysis X Timely X Systems‐Oriented Varies Responsive X January 10, 2014 5
*general trends
Rasmussen’s Risk Management Framework
January 10, 2014 6
Government
Regulators & Associa-ons
Company
Management
Staff
Work
J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, pp. 183‐213, 1997.
Rasmussen’s Risk Management Framework
January 10, 2014 7
Provincial Government (e.g. MOHLTC)
Organiza-on Execu-ve (e.g. CEO, clinical VPs)
Clinical Directors
Risk Management
Area Managers
Frontline Staff (e.g. nurses, pharmacists, physicians)
Health Care (e.g. pa-ents)
Federal Regulator (e.g. Health Canada)
Manufacturers (e.g. medical devices, medical products)
Independent Organiza-ons (e.g. ISMP)
Phase 1 – Explore and Compare Incident Learning Systems
• Examine avia7on, nuclear power, and health care (reported trends, 8 diverse systems, and 3 case studies)
• Research focused on areas iden7fied for improvement: – Repor7ng culture – Repor7ng process and analysis techniques – Informa7on dissemina7on and implementa7on of improvements
January 10, 2014 8
Phase 1 – Data Collec-on and Analysis
• For each area for improvement: – Health care ideals (WHO, Rasmussen) – Descrip7on of avia7on, nuclear power, health care
January 10, 2014 9
Repor-ng Culture Repor-ng Process and Analysis
Dissemina-on and Implementa-on
Ideal
Avia-on
Nuclear Power
Health Care 1
Health Care 2
…
Phase 1 – Data Collec-on and Analysis
• For each area for improvement: – Health care ideals (WHO, Rasmussen) – Descrip7on of avia7on, nuclear power, health care
January 10, 2014 10
Repor-ng Culture Repor-ng Process and Analysis
Dissemina-on and Implementa-on
Ideal System details System details System details
Avia-on System details System details System details
Nuclear Power System details System details System details
Health Care 1 System details System details System details
Health Care 2 System details System details System details
… System details System details System details
Phase 1 – Data Collec-on and Analysis
• For each area for improvement: – Compara7ve trends across all systems
January 10, 2014 11
Repor-ng Culture Repor-ng Process and Analysis
Dissemina-on and Implementa-on
Ideal System details System details System details
Avia-on System details System details System details
Nuclear Power System details System details System details
Health Care 1 System details System details System details
Health Care 2 System details System details System details
… System details System details System details
TRENDS TRENDS TRENDS TRENDS
Phase 1 – Poten-al Strategies • For each area for improvement: – Iden7fied poten7al strategies
January 10, 2014 12
Repor-ng Culture Repor-ng Process and Analysis
Dissemina-on and Implementa-on
Ideal System details System details System details
Avia-on System details System details System details
Nuclear Power System details System details System details
Health Care 1 System details System details System details
Health Care 2 System details System details System details
… System details System details System details
TRENDS TRENDS TRENDS TRENDS
POTENTIAL STRATEGIES STRATEGIES STRATEGIES STRATEGIES
Phase 1 – Explore and Compare Incident Learning Systems
• Strengths – Comparing systems objec7vely across same characteris7cs
– Informa7on directly from systems • Limita7ons – Number of systems examined – Could not capture intangible, contextual elements
January 10, 2014 13
Phase 2 – Refine Poten-al Strategies for Health Care
• Focus groups and in‐depth interviews with stakeholders at all Rasmussen levels
• Ques7ons to: – Understand current processes in health care – Evaluate end‐user needs – General discussion about areas for improvement – Evaluate poten7al strategies – Brainstorm alterna7ve strategies
January 10, 2014 14
Phase 2 – Refine Poten-al Strategies for Health Care
January 10, 2014 15
Rasmussen Level Par-cipants Focus Group/Interview Topic
Frontline Staff & Management (Clinical, Risk)
1 risk manager, 1 physician, 2 pharmacists, 1 nurse Topic 1 – Repor7ng Culture
Frontline Staff & Management (Clinical, Risk)
1 risk manager, 1 physician, 1 pharmacist
Topic 2 – Repor7ng Process and Analysis Techniques
Frontline Staff & Management (Clinical, Risk)
1 risk manager, 1 physician, 1 pharmacist, 2 nurses
Topic 3 – Informa7on Dissemina7on and Implementa7on of Improvements
Frontline Staff & Management (Clinical, Risk)
1 risk manager, 3 pharmacists, 1 nurse Topic 1, 2, 3
Hospital Execu-ve UHN CEO Topic 1, 2, 3
Regulators Health Canada Topic 1, 2, 3
Government 2 MOHLTC Topic 1, 2, 3
*Par:cipa:on based on availability
Phase 2 – Analysis
January 10, 2014 16
• Transcrip7on • Coding – Sen7ment behind comments – Two coders
• Thema7c analysis – Discussed with second coder
• Relate themes to WHO quali7es and Rasmussen levels
Phase 2 – Refine Poten-al Strategies for Health Care
• Strengths – Discussion between Rasmussen levels – Co‐coding – Theore7cal satura7on of ideas
• Limita7ons – Par7cipants from 1 organiza7on, 1 province – Recruitment and scheduling challenges – Par7cipant bias due to self‐selec7on
January 10, 2014 17
Phase 2 – Themes 1. Current underuse of incident repor7ng systems 2. Need for incident learning educa7on 3. Promote safe culture and ac7vely encourage repor7ng 4. Improve repor7ng process 5. Improve analysis process 6. Need for effec7ve dissemina7on of incident informa7on and
review outcomes 7. Learn from non‐ cri7cal/severe incidents and near‐misses 8. Increase systems improvements resul7ng from incident
repor7ng and review 9. Dedicate addi7onal resources to support incident learning 10. Balance commitment to public transparency with protec7on for
health care professionals and ins7tu7ons January 10, 2014 18
Phase 2 – Suggested Approaches and Strategies
January 10, 2014 19
Approaches Suggested Strategies
Theme 1 (Need)
Approach 1 Strategy 1
Strategy 2
Approach 2 Strategy 3
Theme 2 (Need)
Approach 3
Strategy 4
Strategy 5
Strategy 6
Approach 4 Strategy 7
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 20
Stakeholder Feedback & Sugges-ons +
Proven Strategies from Avia-on & Nuclear Power =
PROPOSED STRATEGIES
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 21
Government
Regulators
Independent Organiza-ons
Senior Management
Risk Management
Area Management
Frontline Staff
Health Care
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 22
WHO Quality Proposed Strategies
Non‐puni7ve
1. Educa7on and training for the frontline staff about the complete process: a. Presenta7ons at new employee orienta7ons. b. Recurring hands‐on workshops on units. c. eLearning modules.
2. Incorporate incident learning outreach into November Pa7ent Safety Month.
3. Appoint more Pa7ent Safety Officers in upper management. 4. Give employees posi7ve evalua7ons based on increased repor7ng. 5. Modify terminology around incident repor7ng and learning.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 23
WHO Quality Proposed Strategies
Confiden7al Although health care incident repor7ng systems all protect pa7ent, reporter, and ins7tu7on iden77es, there is s7ll a need to iden7fy strategies to assure reporters of this confiden7ality.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 24
WHO Quality Proposed Strategies
Independent 1. Develop a unified incident repor7ng and learning system established by an external organiza7on.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 25
WHO Quality Proposed Strategies
Expert Analysis
1. Provide report ini7ators with a field to iden7fy contribu7ng factors and preven7on recommenda7ons.
2. Include a process improvement expert in all inves7ga7ons. 3. Train managers on how to facilitate debriefs. 4. Make debriefs mul7‐disciplinary.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 26
WHO Quality Proposed Strategies
Timely 1. Priori7ze incidents for inves7ga7on based on the significance of the
hazards revealed. 2. Model processes aUer those in place in opera7ng rooms.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 27
WHO Quality Proposed Strategies Systems‐oriented
1. Emphasize the main objec7ve of incident repor7ng as quality improvement.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 28
WHO Quality Proposed Strategies
Responsive
1. Formalize standard processes for all incidents and near‐misses. 2. Disseminate incident informa7on and lessons learned using a
combina7on of regula7ons, standards, policies, alerts, newsle?ers, bulle7ns, digests, research exchanges, mee7ngs, and eLearning educa7on modules, depending on the organiza7on.
3. Facilitate frontline genera7on of aggregate incident reports by event type.
4. Combine exis7ng mandatory morbidity and mortality rounds with incident repor7ng and learning processes.
5. Create a shared central database for par7cipa7ng organiza7ons to submit and view incidents.
Proposed Strategies to Improve Health Care Incident Repor-ng and Learning
January 10, 2014 29
WHO Quality Proposed Strategies
Convenience and ease of repor7ng
1. Improve the repor7ng plalorm. 2. Improve the repor7ng form. 3. Tailor repor7ng forms to be appropriate for each profession’s
structures and workflows.
Contribu-ons and Significance
• Proposed strategies to address shortcomings and achieve best incident learning prac7ces – Effec7ve and efficient system design – Decrease preventable errors and deaths
• Examined en7re incident learning process and interac7ons, not components in isola7on
• Proac7ve applica7on of Rasmussen’s risk management framework
January 10, 2014 30
Future Direc-ons
• Validate findings across ins7tu7ons and regions • Further specifica7on on approaches and strategies – Explore intangible quali7es in avia7on and nuclear power
– User‐centred design to detail each strategy • Implement strategies
January 10, 2014 31
Thank you.
Ques-ons?
January 10, 2014 32
Risk Management Frameworks
• Failure Modes and Effects Analysis
• Fault Tree Analysis • Probabilis7c Risk Assessment
• Many more…
January 10, 2014 33
Office of the Auditor General of Canada, "October Report of the Auditor General of Canada: Chapter 5 ‐ Keeping the Border Open and Secure ‐ Canada Border Services Agency," 2007.
Rasmussen’s Risk Management Framework
• Strengths – Models informa7on flow through a system – Illustrates how organiza7on levels support each other
– Accounts for interconnec7vity of all system components
• Weaknesses – Does not include more “abstract”, non‐structural quali7es associated with successful systems
January 10, 2014 34
Avia-on Mapped to Rasmussen’s Framework
January 10, 2014 35
FAA and NTSB (independent from FAA)
ASRS (administered by NASA)
Airlines
Staff (e.g. pilots, flight acendants, dispatchers, air traffic controllers, manufacturers)
Avia-on (e.g. aircrae, workflows)
Nuclear Power Mapped to Rasmussen’s Framework
January 10, 2014 36
IAEA/NEA AIRS
Na-onal Regulator (and na-onal coordinator)
Plant Management
Staff (e.g. operators)
Nuclear Power Plant
Phase 1 – Literature Review
January 10, 2014 37
Systems Studied Incident Repor-ng System Administering Organiza-on Loca-on
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ University Health Network (UHN) Toronto, Ontario Canadian Medica7on Incident Repor7ng and Preven7on System (CMIRPS) & Analyze‐ERR (a standardized tool provided for use in ins7tu7ons)
Ins7tute for Safe Medica7on Prac7ces (ISMP) Canada
Manufacturer and User Facility Device Experience (MAUDE) (mandatory reports from manufacturers) & MedWatch (voluntary reports from prac77oners)
Food and Drug Administra7on (FDA) United States
MedMARx United States Pharmacopeial United States Na7onal Centre for Pa7ent Safety (NCPS) Veterans Health Administra7on (VA) United States
Australian Incident Monitoring System (AIMS) Australian Pa7ent Safety Founda7on (APSF) Australia
Na7onal Repor7ng and Learning System (NRLS) Na7onal Health Service (NHS) Na7onal Pa7ent Safety Agency (NPSA)
Great Britain
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Boots Pharmacies Great Britain
Case study Massachuse?s General Hospital, Department of Anesthesia, Cri7cal Care, and Pain Medicine
Boston, Massachuse?s
Case study of C. difficile ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Ontario, Canada Case study Department of Anesthesia Geelong, Australia
January 10, 2014 38
Details of Interest Area for Improvement Ques-ons
Repor-ng culture
What are the system’s objec7ves? What is the repor7ng culture? How is it encouraged, created, and maintained? Is the system puni7ve or non‐puni7ve? Is the system iden7fying, confiden7al, or anonymous? Who are reports submi?ed to? Who are reports analyzed by? Does the system adopt a systems approach to error analysis or human? Who has access to the system?
Repor-ng process and analysis techniques
Is the system mandatory or voluntary? Who reports? What is reported? How long aUer an incident are reports filled out? How are reports entered? How long does it take to fill out a report? Are events classified and coded? If so, how? How is data analyzed and used?
Dissemina-on of informa-on and implementa-on of improvements
Who disseminates the results of an analysis? What informa7on is disseminated? How is informa7on fed back to reporters and the community? Who does feedback reach? Is anyone accountable for ac7ng on informa7on disseminated? If so, who? What is the 7ming of dissemina7on? How is the system searched? How standardized is the system (e.g. across a region or discipline)? How is this level of standardiza7on achieved?
January 10, 2014 39
Poten-al Strategies for Repor-ng Culture
January 10, 2014 40
Poten-al Strategy System Iden-fied From Provide legisla7ve immunity to reporters. Avia7on Report to an organiza7on with no puni7ve powers. Avia7on, ISMP, AIMS Truly blameless, systems approach to error analysis. Avia7on, nuclear power Emphasize trust, openness, and honesty through policies and examples. Nuclear power
Change industry connota7ons around standard procedures (e.g. checklists, instrumenta7on, repor7ng) from detrac7ng from professionals’ art to disciplined prac7ce to be encouraged.
Avia7on
Unions for frontline staff. Avia7on, nuclear power, nursing
Enforce disciplinary ac7ons if an event is NOT reported. Boots Pharmacies Remove sec7on with all iden7fying informa7on from the report before entry into the permanent database and return it to reporter to ensure confiden7ality.
Avia7on
Introduce legisla7on to prevent incident informa7on disclosure to the public. Ontario health care
Poten-al Strategies for Repor-ng Process and Analysis Techniques
January 10, 2014 41
Poten-al Strategy System Iden-fied From Voluntary to report near‐misses and mandatory to report incidents within an organiza7on, but voluntary to report anything on a na7onal or interna7onal level. Avia7on, nuclear power
Hazards, near‐misses, and all incidents reported to the same system. Avia7on, nuclear power Paper and electronic repor7ng. Avia7on
Repor7ng completed through exis7ng medical record. Department of Anesthesia, Massachuse?s General Hospital
Mobile repor7ng. Department of Anesthesia in Geelong, Australia
Repor7ng form approximately three pages in length. Avia7on Combina7on of structured fields with areas for free‐text descrip7ons. Avia7on, some health care Unique repor7ng forms based on profession of reporter. Avia7on, NHS Require basic event informa7on with event descrip7on, preliminary analysis, and recommenda7ons. Avia7on, nuclear power
Reports are analyzed and/or disseminated by an influen7al organiza7on to ensure the resul7ng recommenda7ons are the strongest possible and are not limited by feasibility concerns.
Avia7on, nuclear power
Involve the reporter throughout the analysis and recommenda7on development to promote effec7ve recommenda7ons and prompt implementa7on of improvements.
Nuclear power
Events are coded and classified according to some criteria. Avia7on, nuclear power Root cause analysis, beyond the most proximal cause to the system failure. Avia7on, nuclear power Extent of condi7on and cause evalua7ons. Nuclear power
Generate and release performance metrics. AIMS, Department of Anesthesia in Geelong, Australia
Poten-al Strategies for Dissemina-on of Informa-on and Implementa-on of Improvements
January 10, 2014 42
Poten-al Strategy System Iden-fied From Organiza7onal structure and escala7on hierarchy within industry is simplified, clearly defined, and standardized. Avia7on, nuclear power
Informa7on is disseminated by the organiza7on that analyzes reports. Avia7on, most health care Informa7on is disseminated up and down Rasmussen’s hierarchy without skipping any levels. Nuclear power
Communica7on should be tailored and unique for audience (i.e. management, frontline staff, media, public).
Avia7on and nuclear power
Methods of informa7on dissemina7on include regula7ons, standards, alerts, bulle7ns, newsle?ers, studies, and mee7ngs.
Avia7on, nuclear power, and health care
Relay excerpts from de‐iden7fied reports along with the lessons learned. Avia7on
Informa7on is aggregated and available to look through by topic. MAUDE, NHS Incident database is accessible through a search engine. Avia7on, nuclear power Management is held accountable for making and monitoring improvements and is responsible for communica7ng back to the centralized body.
Nuclear power
Phase 2 – Focus Groups and Interviews
January 10, 2014 43
Transcrip-on and Coding
January 10, 2014 44
Ques-on Strategy Comment Code
Thema-c Analysis
January 10, 2014 45
Code Quota-on
Theme 1
Subtheme 1
Code 1 P4: Comment
P15: Comment
Code 2 P3: Comment
Subtheme 2
Code 3 P8: Comment
P22: Comment
P15: Comment
Code 4 P11: Comment
P19: Comment
Approaches and Strategies to Address Need for Incident Learning Educa-on
January 10, 2014 46
Approaches Suggested Strategies
Define and communicate the objec7ves of incident repor7ng.
Objec7ve: to provide aggregate quality data. Objec7ve: to drive systems and process improvements.
Define and communicate what events should be reported and by who.
Report anything not done according to policy. Report anything that can be improved.
Provide transparency to frontline staff on the analysis and quality improvement aspects of the process beyond report submission.
Educa7onal outreach to frontline.
Educate frontline about QCIPA. Educa7onal outreach to frontline.
Engage physicians in incident repor7ng and learning.
Connect exis7ng mandatory physician quality improvement processes (e.g. morbidity and mortality rounds, quality review commi?ees) with the rest of the organiza7on and central incident learning systems. Emphasize the value that incident repor7ng and learning add beyond exis7ng processes. Involve physicians early in their training.
Standardize incident inves7ga7on processes. Train managers on how to facilitate incident reviews.
Educa7onal outreach to all stakeholders (e.g. frontline staff, managers).
Presenta7on at new employee orienta7on. Frequent hands‐on workshops and educa7onal sessions on units. Mandatory con7nuing educa7on eLearning modules.
Approaches and Strategies to Promote Safe Culture and Ac-vely Encourage Repor-ng
January 10, 2014 47
Approaches Suggested Strategies Enable follow‐up with report ini7ator during inves7ga7on, while easing reporter trepida7ons about being linked to a report.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Encourage culture of sharing and support among colleagues.
Ini7ate culture shiU within leadership. Emphasize main objec7ve as quality improvement. Inves7gate reports and actually use to inform quality improvement.
Emphasize repor7ng of posi7ve events. Educa7onal outreach to all stakeholders. Redesign terminology used around incident repor7ng.
Increase visibility of incident repor7ng.
Tie incident repor7ng and learning in with other safety ini7a7ves (e.g. November “Pa7ent Safety Month”). Increase number of Pa7ent Safety Officers. Evaluate employees, units, and sites on repor7ng levels (increased repor7ng results in a posi7ve evalua7on).
Approaches and Strategies to Improve Repor-ng Process
January 10, 2014 48
Approaches Suggested Strategies
Make the incident repor7ng plalorm more accessible and user‐friendly.
Allow access to incident repor7ng systems from non‐hospital‐based computers. Use consistent login informa7on across organiza7on computer systems. Enable repor7ng on mobile technologies. Provide the ability to save an incomplete report and return to submit later. Offer spell‐check in system. Eliminate character limits on fields. Provide the func7onality to upload videos and pictures pertaining to an incident.
Redesign incident repor7ng forms.
Length of repor7ng form: 5 minutes to complete. Use combina7on of structured and free‐text fields. Pa7ent informa7on should be an op7onal field so condi7ons with no pa7ent harm can be reported. Provide field for frontline reporter to iden7fy incident causes and preventa7ve strategies. Classify incidents by pa7ent harm and extent of problem separately. Add “unable to assess” op7on for classifica7on.
Increase the applicability of the repor7ng process to a variety of professional workflows and organiza7on structures.
Have different repor7ng forms for each profession. Modify repor7ng workflow to allow for mul7‐disciplinary input.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Structure the repor7ng form to reflect and guide the analysis process.
Determine the ideal 7ming for report ini7a7on. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Approaches and Strategies to Improve Analysis Process
January 10, 2014 49
Approaches Suggested Strategies
Formalize the incident inves7ga7on process.
Step‐ by‐step instruc7ons for inves7gators to follow that leads team through equal considera7on of all possible contribu7ng factors (e.g. systems, environment, workflow, human).
Ensure the inves7ga7on team is made up of people who together can produce the most valuable outcomes.
Mul7‐disciplinary debriefs. Involve a process improvement expert in all debriefs.
Determine if people involved in an incident should be included in the debriefing process.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Determine how close to units debriefings should be held. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Determine the ideal 7ming for incident analysis. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Approaches and Strategies to Address Need for Effec-ve Dissemina-on of Incident Informa-on and Review Outcomes
January 10, 2014 50
Approaches Suggested Strategies Maintain, but connect de‐centralized incident learning and quality improvement efforts.
Arrange for representa7ves from each de‐centralized commi?ee to meet periodically.
Have individual commi?ees submit to and access a centralized database with all incidents, near‐misses, and hazards.
Create mechanisms and channels for organiza7ons to share with and learn from each other.
Adopt standards across health care ins7tu7ons in terms of terminology, reference points, and procedures. Establish central, independent health care organiza7ons across regions and disciplines to facilitate sharing and learning across organiza7ons. Offer free par7cipa7on in centralized program. Structure informa7on flow according to Rasmussen’s hierarchy (i.e. each level receives reports from the one below and lead reporters report relevant incidents to the one above).
Ensure incident informa7on and review outcomes are communicated back to frontline.
Disseminate aggregate incident informa7on by event type with select de‐iden7fied incident narra7ves, lessons learned, and recommenda7ons. Feed informa7on back to managers and require them to determine what is appropriate for their units and communicate it to their staff. Release incident summary bulle7ns. Publish monthly incident newsle?ers. Par7cipate in quality improvement research exchanges. Provide online incident digests. Develop eLearning con7nuing educa7on modules based on incident review outcomes. Create new policies informed by incident inves7ga7ons. Create a searchable database to enable frontline staff to self‐generate summary incident reports. Store aggregate incident informa7on in an archive available to frontline retrospec7vely.
Keep report ini7ator informed as his/her report is processed.
Issue a “thank you for submiung an incident report” message from a prominent person in the organiza7on. Provide no7fica7ons when a report has been added to and/or signed‐off on Directly communicate the outcomes of the incident review to the report ini7ator. Providing the report ini7ator with research and informa7on related to their incident.
Approaches and Strategies to Learn from Non – Cri-cal/Severe Incidents and Near‐Misses
January 10, 2014 51
Approaches Suggested Strategies
Emphasize proac7ve incident repor7ng and learning.
Instate formal review procedures for moderate/minor incidents, near‐misses, and hazards.
Approaches and Strategies to Increase Systems Improvements Resul-ng from Incident Repor-ng and
Review
January 10, 2014 52
Approaches Suggested Strategies Ensure capturing complex inherent systems issues. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Formalize a mandatory incident inves7ga7on process.
Incident review recommenda7ons should consider using technology to reduce load on humans.
Decrease the response 7me in addressing incident reports.
Use opera7ng room incident review processes as a model for other health care areas.
Ini7ate systems improvements at senior management level. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Approaches and Strategies to Dedicate Addi-onal Resources to Support Incident Learning
January 10, 2014 53
Approaches Suggested Strategies
Priori7ze incident reports for in‐depth inves7ga7on.
Leave decision about whether an incident merits a full inves7ga7on to manager’s judgement. Annually iden7fy the top five systemic problems to be addressed.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Increase size of and resources available to risk management departments.
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Keep organiza7on computer systems up‐to‐date.
Approaches and Strategies to Balance Commitment to Public Transparency with Protec-on for Health Care
Professionals and Ins-tu-ons
January 10, 2014 54
Approaches Suggested Strategies Be transparent to the public, but enable health care professionals to discuss incidents safely.
Pass legisla7on similar to QCIPA.
Release enough incident detail to be meaningfully interpreted without implica7ng individuals or ins7tu7ons.
Release aggregate informa7on about pools of hospitals, grouped together by size, loca7on, complexity of cases seen.