Embed Size (px)
Citation preview
Analysis of Actions Following Adverse Patient Safety Events: Lessons Learned for Preventing ReoccurrenceTrish Hunt, BSN, MSc, CPHRM, Director, Risk Management, Jessica Jaiven, BSc, MSc, MPH, Project Director, Georgene Miller, RN, MSN, Vice President
Quality, Safety & Outcome Improvement, Provincial Health Services Authority, British Columbia, Canada
Who we are:Specialized Health Care Services to Some of the Most Vulnerable People in BC, Canada
• Provincial Health Services Authority (PHSA) is one of six health authorities – the other five health authorities serve geographic regions of BC, Canada. PHSA's primary role is to ensure that BC residents have access to a
coordinated network of high-quality specialized health care services.
• PHSA operates several provincial agencies such as BC Women’s and Children's Hospitals, BC Transplant, BC Cancer Agency, BC Centre for Disease Control and Emergency Health Services.
• Also responsible for specialized provincial health services like chest surgery and trauma services, which are delivered in a number of locations in the regional health authorities as well specialized programs that operate across several PHSA agencies.
PHSA VISION, MISSION, VALUES STRATEGIC PLAN
Stra
tegi
c Plan
Ena
bler
s: P
rovin
cial P
olicy
, In
form
atio
n Ma
nage
men
t, Or
gani
zatio
nal C
apac
ity,
Healt
h Hu
man
Res
ourc
es, In
frast
ruct
ure C
apac
ity,
Fina
ncial
Cap
acity
, Par
tner
ship
s
Peop
leLe
ader
ship
VALUE FOR THE PATIENT
Effectiveness Safety Access Efficiency Continuity Patient
CentredPopulation
FocusWork Life
QUALITY DIMENSIONS
SUSTAINABLE QUALITY PATIENT OUTCOMES
PHSA QUALITY FRAMEWORK
RPIWFMEARCA
SBAR
Protocols/Guidelines
Standard workCCMs
High Reliability Organization
CommunicationReporting Measuring Evaluation
Sustainable Health Care
PATIENT & FAMILY
Standards Methods Outcomes
Accreditation ROPs
Culture of Quality & Safety
Cross-cutting themes – Quality & Safety, Learning and Research
Cross-cutting imPROVE Management System
A High Reliability Organization with a Just Culture
• We strive to be a High Reliability Organization (HRO) where a culture of patient safety is nurtured.
• Our Quality and Safety framework articulates our organization’s enablers and cross-cutting themes of quality, safety, learning and research, aligned to eight major quality dimensions. With patients and families in the centre and our strategic direction, we strive to provide value to the patient and ensure sustainable quality patient outcomes.
PurposeIn our efforts to be a highly reliable organization, we analyze reoccurring themes from our critical patient safety event reviews (CPSERs) to help:
• Focus on recommendations/actions arising from CPSERs• Review trends in root causes, contributing factors and system deficiencies• Identify areas of continuing vulnerability• Target and prioritize quality improvement efforts to address common safety concerns• Track and trend sustainability of improvement gains
Methodology• Data collection• All critical patient safety events (CPSERs):• Events with significant patient harm and/or death) • 2009 to 2011• n = 124 • 545 actions
•Data analysis• Actions arising from CPSERs were categorized into 5 themes:• Following of Standard Operating Procedures• Education/Training• Communication• Technical Performance• Availability/Access to Services
• Frequencies calculated for each theme and sub-theme to determine prevalent/reoccurring actions.
Results: Summary of Dominant ThemesThe top three most prevalent or reoccurring actions (greatest % of critical events with these particular actions/recommendations):
1.Following Standard Operating Procedures Examples: • Development or revision of policies, care guidelines/ pathways• Documentation of care and health status• Checking/ processing of physician’s orders
2.Technical Performance (Services, Systems, Scheduling, Equipment) Examples:• Equipment / infrastructure • Job/task/system redesign • Alert/follow-up systems for patient results
3.Education and Training Examples:• Assessment and diagnostics• Team members’ roles and responsibilities• Treatment/management and consultation for deteriorating patient conditions
Trish Hunt – [email protected] Jaiven – [email protected] Miller – [email protected] Fuller Blamey – [email protected]
Conclusions• Themes are consistent with the level and complexity of care provided in tertiary /specialized care agencies and with the patient safety literature regarding adverse events.
• Findings support our prioritizing and targeting of quality improvement efforts on those actions that are commonly re-occurring. Examples:
• Intensive process flow mapping and mistake proofing of unprocessed physicians’ orders• Team communication strategies/development• Handoffs and transitions care framework, policy and tools
• Continue to improve the CPSER process in PHSA • Leadership• Patient safety and quality knowledge—building competency & capacity• Process standardization• Communication about learning/improvements and measurement
Going Forward• Continue to trend and analyse actions within each event and across events• More attention to developing and implementing rigorous actions• Monitoring effectiveness of actions and ensuring sustainability• Continue to advocate stronger system level improvements
Examples: • Promoting just culture of safety• Closing the loop with staff and leaders on all events• Reporting of near misses and events• Team work• Safety rounds and audits• Clinical care management protocols
• Combine different quality improvement and analysis methods, e.g. RCA and FMEA and LEAN methodology
Key Take Away Messages• Culture is key to provide higher quality, safer care to patients and decrease adverse events, complaints and claims
• No news is not good news!• Encourage non-punitive reporting of safety issues at every opportunity
• Learn, Learn, Learn and Don’t Forget to Share • Results communication of lessons learned and proactive changes made, particularly for direct care staff is essential. Close the loop!
• Highly reliable organizations• Continually engage in proactive study of patient safety events and near misses • Learn from mistakes, to more fully understand corrective actions • Create resilient and sustainable systems to prevent them in future
