b3 rapid fire: preventing medication chaos - s. fuller-blamey

B3: Paying Attention to Near Misses Prevents

Actual Harm

BCPSQC Quality Form 2012

March 8, 2012Sue Fuller Blamey

Background – Near Miss Reporting

• A near miss is defined as an event that could have resulted in unwanted consequences but did not because either by chance or by timely intervention, the event did not reach the patient (CPSI).

• High Reliability Organizations regard near misses as system failures that reveal potential danger or evidence of success since potential harm was avoided.

Analysis of Patient Safety Events

System improvements have a 4-pronged approach:

Reactive: Analysis of actual events with some degree of harmAnalysis of aggregate data

Proactive:Analysis of near miss eventsAnalysis of errors that have occurred in other organizations

Proactive vs Reactive

Looking at these

Can help prevent these

Barriers to Near Miss Reporting MacPhee & Sherrard CPSI

• Fear and lack of belief that reporting results in improvement

• Fear of blame – culture of safety in the organization

• Method of reporting

Fostering a Just Culture for Reporting

•All health care team members must feel that they are contributing to patient safety by reporting

•When organizations pay attention to near misses and put strategies in place to prevent near misses, the number of actual patient safety events will be

reduced.

PHSA Quality & Safety Framework

PHSA VISION, MISSION, VALUES &STRATEGIC PLAN

Str

ateg

ic P

lan

Ena

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s: P

rovi

ncia

l Pol

icy,

O

rgan

izat

iona

l Cap

acity

(Org

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atio

nal,

Hea

lth H

uman

R

esou

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, Inf

orm

atio

n M

anag

emen

t, In

fras

truc

ture

C

apac

ity, F

inan

cial

Cap

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), P

artn

ersh

ips

Peo

ple

Lead

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ip

Effectiveness

Safety Access Efficiency ContinuityPatientCentred

PopulationFocus

Work Life

QUALITY DIMENSIONS

RPIWFMEARCA

SBARPSLS

ProtocolsGuidelines

CCMsStandard work

Checklists

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

SUSTAINABLE QUALITY PATIENT OUTCOMES

VALUE FOR THE PATIENT

PHSA QUALITY & SAFETY FRAMEWORK

PHSA Near Miss Project

• Educate staff about Near Miss Event reporting

• Analyze all of Near Miss Events per year

• Identify trends and 2 – 3 projects per agency per year

• Create improvement project teams

• Develop and implement solutions to prevent recurrence of same type of event

• Sustain gains

Types of PHSA Near Miss Event Projects

Two identifiers Physicians Verbal Orders

Dangerous Abbreviations Accurate Laboratory Reports

Medication Preparation Handovers & Transitions

Prevention of Unprocessed Orders

Morphine Dosing Errors

Mislabeled Specimens ID of Patient with Mental Health Concerns

Medication Reconciliation Documentation

PHSA Actual vs Near Miss Patient Safety Events

BC Cancer Agency Near Miss Reporting

BC Centre For Disease Control Lab Project

PHSA Patient Safety Events

PHSA Patient Safety Events Category of Event - Behaviour

BC Women’s Nitroglycerine Project # of Medication Events

BCCA Prevention of Unprocessed Orders Leading to Missed Chemotherapy Appts

BCCA Prevention of Unprocessed Orders

% of Physician Order Defects

0%

10%

20%

30%

40%

50%

60%

70%

80%

Month

% o

f P

hysic

ian

Ord

er

Defe

cts

% of Physician OrderDefects

BC Children’s Patient Identification Project

BCMHAS – Forensics & RVH Medication Administration Process Project

Forensics # of Medication Events d/t Med Administration Issues

0

5

10

15

20

25

30

2009 2010

Year

# of

Eve

nts Near Miss

Actual

Riverview # of Medicaton Events d/t Med Admin Process

0

10

20

30

40

50

60

70

2009 2010

Year

# of

Eve

nts

Near Miss

Actual

PHSA Medication Patient Safety Events