Root Cause Analysis: How Incident Reports Lead to

Improvements

Matt Russell, MD Glenn Rosenbluth, MD

Patient RW

• 64yo male with new onset seizure-like activity with right hemiplegia, altered mental status

• After consulting neurology, decided to get MRI with lumbar puncture; MRI was performed under GA due to deteriorating mental status

• MRI results inconclusive, so LP performed while patient was still under GA

Patient RW

• In the interim, Neurology also reviews the MRI and adds additional recommendations which are texted to the Medicine intern

• Next morning, RW is told that the LP studies looked normal. He hadn’t realized that the LP was even performed, and is angry about this.

• Neurology recommends additional LP to complete studies which weren’t done.

• Was there an error in RW’s care? – How would you classify the error(s)

• Was there an adverse event?

– If so, was it preventable?

• Should an Incident Report be filed? – If so, by whom?

Root Causes of Sentinel Events

Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011)

Error Adverse Event

PAE

Preventable Adverse Event harm caused by error

Definitions Adverse Event

an injury caused by medical management

(“harm”)

Error failure of a planned action

to be completed as intended or use of a wrong plan

to achieve an aim

Error Adverse Event

PAE

All Errors are not created equal

Not all errors result in adverse events Not all adverse events are caused by errors

Human Factors Types of Individual Errors

• Slips – Unintentional mistakes of automatic processing

• Knowledge-based Errors – Lack of knowledge coupled with lack of awareness

of knowledge deficit

• Rule-based Errors – Situation or problem is misclassified

Adapted from Washington State Medical Board and AHRQ

• Was there an error in RW’s care? – How would you classify the error(s)

• Was there an adverse event?

– If so, was it preventable?

• Should an Incident Report be filed? – If so, by whom?

A Root Cause Analysis (RCA) is convened

Root Cause Analysis

• Safe, blame-free, protected • Structured retrospective analysis of events • Multidisciplinary • Focus on systems and processes, not

individual performance • Identify and implement improvement actions

to prevent recurrence

Root Cause Analysis

• What happened? • Why did it happen? • What do we do to prevent it from happening

again?

• Goal: Quality improvement (Improve our systems of care)

Mock Root Cause Analysis (RCA)

Important Updates

• Incident Reporting • Universal Protocol for

Perioperative/PreProcedure Verification • Consent

Reporting Medical Errors

• UCSF Incident Reporting System – Online – Near misses, medical errors, adverse events – Approx 10,000/year

• Medication Related Events • Skin Issues (for hospital acquired pressure ulcers) • IVs Tubes and Drains (largely for IV infiltrates) • Falls

UCSF Incident Reporting System

Reporting at SFGH

• Patient-related incidents – Enter through Invision/LCR – Access the patient – Click on “UO/Suggestion Box”

• Non-Patient Related: – Enter on intranet site: http//insidechnsf.chnsf.org – Click on the UO icon

• If it asks you to re-login, use your regular login

Reporting at VAMC

• Report: Adverse events, close calls, risk-prone conditions

• Enter all patient-related incidents via CPRS – Select patient – Tools → More → QI Reporting

• Other incidents or no CPRS access? – SFVA Patient Safety Managers: 415-221-4810

extension 4756 or extension 2018.

What happens to Incident Reports?

• Categorized and Routed – Category manager, nurse manager, service chief

• Investigation and Review • Improvement activities and follow up plans • All documented in the IR system

• Serious incidents are quickly escalated to

leadership for review and consideration of a root cause analysis

Tell a chief or attending, and complete an Incident Report The GME Confidential Hotline can be used in some circumstances

Universal Protocol

• Pre-procedure verification process – Person, site, procedure

• Pre-procedure verification process – Person, site, procedure

• Marking the procedural site • Pre-procedure verification

– Checklist

Who is responsible? • We all are! • You, if your are the proceduralist

• What procedures require it?

– (1) all procedures performed in an operating room – (2) all procedures performed under moderate or deep

sedation or general anesthesia, regardless of setting – (3) invasive procedures performed without sedation.

– Routine minor procedures, such as venipuncture,

peripheral IV line placement, foley catheter insertion and nasogastric tube insertion are not included.

Informed Consent

• Competent adults, legally emancipated minors, parents of minors, conservators

• "Incompetence" does not require a determination of legal incompetency – May include temporary incapacity

• Patient’s preferred language should be used

Why are handoffs important? • Handoffs are linked to medical errors

– Interviews with postcall interns estimate at least 7.5 per 100-patient-days (average 1/night)

– 59% of residents reported that one or more patients were harmed during their most recent rotation due to handoff problems

• 12% reported that harm was major

Kitch, 2008; Horwitz 2008

What is the right information?

• U of Chicago: Study of handoffs – Asked senders to guess what receivers would say was

the most important information for each patient

• Most important information was NOT successfully communicated 60% of the time

• Did not agree on the rationales provided for 60% of items – At times contradictory

Chang V, et al. Pediatrics 2010

UCSF Handoff Policy

“Each training program must design clinical assignments to minimize the number of transitions in patient care”

– Day/night teams – Staggering of intern/resident/attending switch times

and/or days to maintain continuity, – Outpatient clinic “pods” or teams – Schedule overlaps should include time to allow for

face-to-face handoffs

One approach: The I-PASS mnemonic

I Illness Severity Stable, “Watcher,” Unstable

P Patient Summary Summary statement; events leading up to admission; hospital course; assessment; plan

A Action List To do list; timeline and ownership

S Situation Awareness & Contingency Planning Know what’s going on; plan for what might happen

S Synthesis by Receiver Receiver summarizes, asks questions; restates key action/to do items

© I-PASS Study Group, Children’s Hospital Boston

Handoffs should include at least:

• Patient summary (exam findings, labs, clinical changes) • Assessment of illness severity • Active issues (including pending studies) • Contingency plans (“If/then” statements) • Synthesis of information (e.g. “read-back” by receiver

to verify) • Family contacts • Any changes in responsible attending physician; • An opportunity to ask questions and review historical

information Approved, GMEC: July 18, 2011

Editorial Revision Approved, GMEC: September 26, 2011

TeamSTEPPS Tools

Cross Monitoring

Night team recognizes medication error during handoff and informs the day team

Brief Night team goes over action list and divides tasks and new admits and plans for time to regroup

Debrief In the morning, the night team and day team discuss what went well with the handoff and items the night team would have liked to know

Huddle A patient is unstable, the day and night team examines the patient together and discusses plans for the night with the nurse

Check-Back The intern obtains new information to add to the hand off from the senior resident, this information is repeated by the intern to confirm communication

© I-PASS Study Group, Children’s Hospital Boston

What do I do if… (when…)

• Ask for help • Tell your program directors or chiefs • Report problems

– Incident Reports, Near miss reports – Let us know: glenn.rosenbluth@ucsf.edu

• Participate in an RCA

Tell a chief or attending, and complete an Incident Report The GME Confidential Hotline can be used in some circumstances