Incident Analysis Learning Program - Module Four

Comprehensive Analysis Method Jan. 10, 2013

Welcome

Sandi Kossey Ioana Popescu Erin Pollock Tina Cullimore

WHAT HAPPENED?

HOW AND WHY?

WHAT CAN BE DONE?

WHAT WAS LEARNED?

M3 Learning Program

Analysis Methods

• Canadian Incident Analysis Framework

• Systematic Systems Analysis

• Local framework • Other (VA, NPSA)

Learning Objectives

The knowledge elements include an understanding of the: • Steps to take when undertaking a comprehensive analysis • Benefits and limitations of different diagramming tools • Various considerations when writing statements of

findings The performance elements include the ability to: • Describe the steps to create a timeline of the event • Perform the main steps to analyze information to identify

contributing factors and relationships

Agenda

3-parts

• Knowledge expert

• Practice leader

• Facilitated discussion

7

Introducing: WebEx

11-Jan-13 7

Be prepared to use: - Raise Hand & Checkmark - Chat & Q&A - Pointer & Text

About You M2

Presentation

Wayne Miller

Has this ever happened in one of your facilities?

3:45 pm Call from Nurse manager – Patient has been given the wrong medication. Patient is unconscious and has been moved to the ICU and assessment is ongoing.

Individual Perspectives to Leading Practices

Key Features of Incident Analysis • Timely, Thorough • Objective and Impartial (avoid conflicts of interest or perceived

conflicts) • Credible • Interdisciplinary, Including Frontline, Patient/Family, and Non-

regulated staff Practise / Preparing • Who, When, and How is the analysis conducted in your

organization • Build Teams - Quality, IT, Health Records, Bio Med • Run simulations • Just and trusting culture encourages, supports, and

expects the reporting of safety and learning events.

M2

Page 39 Canadian Incident Analysis Framework

Gather Information

• Caution…Do not jump to solutions, conclusions, and assumptions.

• Caution…The team will not understand the contributing factors related to the incident if they do not understand the circumstances surrounding the incident.

• Caution…The facilitator must have systematic processes for identifying the gaps in information and for accurately addressing those gaps.

WHAT HAPPENED?

• Get a Game Plan – Each Incident is different • Gather Information

• Review the Incident (Occurrence) Report • Review Additional information

• Create a Detailed Timeline • Review Supporting Information

Review the Incident Report & Additional information

• Triggers for a comprehensive analysis • Incident report is based on initial understanding • Others

• Review the health record • Conduct interviews • Visit the location where the incident occurred • Secure items OR look at similar items/devices to

help build that understanding

Create a Detailed Timeline

Example (p.104)

Review Supporting Information

• Includes:

• Review of Policies and Procedures • Look at previously reported similar incidents • Environmental Scan

• Literature Search • Policies and Practices in leading organizations

• Consultation with colleagues or experts in the field.

HOW AND WHY IT HAPPENED?

• Analyze information to identify contributing factors and relationships • Uses systems theory and human factors • Uses diagramming

• Summarizes findings

Analyze Information

• Build on understanding by asking questions to determine contributing factors and relationships of factors to the event. • Appendix G, Page 89, Guiding Questions

• Allows lens to focus on system issues which may have contributed to the event—rather than focus on the person

• What was this influenced by? • What else affected the circumstances?

Use Systems Theory and Human Factors

Systems Theory Focuses on an assessment of

the individual’s action within the context of the circumstances at the time, NOT on the individual alone.

Human Factors Interaction between the

human and the system

Use Diagramming

• Identify and understand inter-relationships between and among contributing factors

• Provides a map which, when used correctly, helps the team identify the “route” which was taken and why it was taken.

• Shifts the focus from the person to the system in which the person works.

Diagramming—Ishikawa Diagram

Diagramming—Tree Diagram

Constellation Diagramming—5 steps

• Step 1: Describe the incident • Step 2: Identify potential contributing factors

• Step 3: Define inter-relationships between and

among potential contributing factors. • Step 4: Identify the findings • Step 5: Confirm the findings with the team

Guiding Questions

Appendix G (p. 89) Example

Summarize Findings

• Statements of findings • Describe the relationships between the contributing

factors and the incident and/or outcome. • Three categories of findings:

Factors that if corrected would likely have prevented the incident or mitigated the harm.

Factors that if corrected, would NOT have prevented the incident or mitigated the harm, but are important for patient/staff safety or safe patient care in general

Mitigating factors—factors that didn’t allow the incident to have more serious consequences and represent solid safeguards that should be kept in place

Statement of Findings

Example “The use of gravity intravenous infusion

sets in the Emergency Department increased the likelihood that an intravenous narcotics infusion would be infused at a higher than intended rate when the patient changed his position on the stretcher”

Confirm Findings

Team should agree on the findings before developing recommended actions

Work through disagreements to achieve consensus If key individuals who were involved in the event were

not part of the analysis team, ask for their feedback on the findings.

Include a Back-Checking Step

Ultimate Goal

To

WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER

WHAT WAS LEARNED?

Healthcare providers work very hard to provide safe care in the best way they know how.

Let’s not ask them to do this risky work without a net

Real-life Experience

Dr. Chris Hayes

Incident Analysis Framework: Real-life Experience

Module 4: Comprehensive analysis method January 10, 2013

What is critical incident (ie. a severe harmful patient safety incident)

• Any unintended event that occurs when a patient receives treatment in the hospital,

– that results in death, or serious disability, injury or harm to the patient, and

– does not result primarily from the patients' underlying medical condition or from a known risk inherent in providing the treatment

• Any unintended event that occurs when a patient receives treatment in the hospital,

– that results in death, or serious disability, injury or harm to the patient, and

– does not result primarily from the patients' underlying medical condition or from a known risk inherent in providing the treatment

• Not factored into the definition at St. Michael’s – perspective of patient outcome is considered

first….harm feels like harm!! – assumes inherent risks are fixed with no

potential in learning or reducing…eg CLI – data supports inherent risk of death d/t

adverse events = 1/116

What is critical incident (ie. a severe harmful patient safety incident)

An example

• Patient admitted to the ICU following a large stroke. At approximately midnight the patient began having generalized seizures. She paged the resident on call. The resident came and asked for some Ativan. As the resident was giving the Ativan he asked the nurse to quickly get some Dilantin (phenytoin). The nurse left the bedside to prepare the medication in an IV minibag, returned to the bedside and began to hang the drug. Meanwhile the Ativan had stopped the seizure and the resident returned to his call room.

• 20 minutes later the patient’s blood pressure rose to 230 over 120 mmHg. The patient began complaining of chest pain and was visibly short of breath. The nurse paged the resident to the bedside STAT. The resident on arrival asked for some IV metoprolol. He gave 20mg in total with little effect on the blood pressure.

An example

• Eventually the patient was stabilized but had suffered a large heart attack and now had significant congestive heart failure.

• Later that evening the resident noticed a vial of phenylephrine at the patient’s bedside. He showed this to the nurse who became immediately very upset and was later sent home.

• The Charge Nurse reported the incident later that evening, the family was informed of the incident and received an apology

• Risk Management & QI team reviewed the incident details and decided that a comprehensive review be conducted

So it’s an adverse event

• The next phase is to analyze the event in order to know: – What happened – How and why it happened – What can be done to reduce the likelihood of

recurrence and make care safer – What was learned

Conducting the analysis

Date / Time Information item Comment / Source Jan 1, 12 22:45 Patient admitted with stroke Patient record

23:35 Patient develops GTC seizure Nurses notes, confirmed by nurse interview

23:40 Resident assessed, gave Ativan and verbally ordered Dilantin 1g over 20 min

Patient record, confirmed by resident interview

23:55 Nurse finished preparing, hung and administered Dilantin

Patient record, confirmed by nurse interview

Jan 2, 12 00:20 Patient blood pressure noted at 230/120, requring more oxygen

Patient record

00:50 Patient’s BP resolved but requiring more oxygen Patient record

~01:20 Bottle of phenylephrine discovered at bedside Interview with resident

~01:50 Bedside nurse relieved of duty and went home Interview with charge nurse

10:30 Echo done and shows Grade 3 LV Patient record

Conducting the analysis

Conducting the analysis

Conducting the analysis

Nurse had to leave bedside to prepare med

Double-check policy does not include anticonvulsants

Sound-alike, look alike drugs stored together

Acute issue, middle of night

Verbal order given

Patient suffers large MI and CHF following wrong drug administration

Hazards Sound-alike look-alike drug

Losses CHF/MI RN/MD Double-check

Medication organization

Purchasing

Manufacturer

“Swiss Cheese” model

What did we do?

What did we do?

Recommendations / Actions

• Introduced TallMan lettering • Removed multi-drug bins and reorganized med

cabinets • Moved phenytoin under “D” for dilantin • Did the same for all other ICUs, then all wards • Met with Clinical Services Committee and

Pharmacy re purchasing of sound-alike, look-alike drugs

• Discussed the problem and the solution openly

Recommendations / Actions

Summary

• Incident analysis is a standard process to learn what, why and how an patient safety incident occurred

• An interprofessional, open and just approach fosters greater learning

• Requires gathering of material facts and interviews of those involved

• Requires open exploration of all contributing system factors

• Done right…leads to effective recommendations and improvement in patient safety

Case Study – Virtual Group Exercise

Most participants will “move” to breakout rooms

Some participants will stay in the main room

Those prompted: click YES to both pop-up screens to “move”

Breakout Session

Small Group Discussion

- Share your organization’s comprehensive analysis process (what works well and what can be improved)

- Point out the differences with the comprehensive method presented (4 objectives, steps, tools)

- What would you need to do tomorrow to make the comprehensive analysis more effective

0 Experience with comprehensive analysis 10

Large Group De-Briefing

Wrap-up

Next Steps

• End of session evaluation certificate of attendance • Follow up survey we learn from you Incident Analysis Learning Program • Concise analysis – January 31, 2013

• Multi-incident analysis – February 21, 2013

• Recommendations management – March 7, 2013

• Follow-through and share what was learned – March 28,

2013

Resource slide

Learning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningProgram/Pages/Session-Recordings-and-Documents.aspx

HQCA’s Systematic Systems Analysis

http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Reviews%20FINAL%20June%202012.pdf

Incident Analysis Tools

http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Pages/Tools.aspx

Thank You

Mulţumesc