A2: Analysis of Adverse Events - T Hunt (PHSA)
19
Analysis of Actions Following Adverse Patient Safety Events: Lessons Learned for Preventing Reoccurrence Trish Hunt, BSN, MSc, CPHRM Director, Risk Management Jessica Jaiven, BSc, MSc, MPH Project Director Quality, Safety & Outcome Improvement, Provincial Health Services Authority Quality Forum March 8, 2012 BC Patient Safety and Quality Council
-
Upload
bcpsqc -
Category
Technology
-
view
672 -
download
0
description
Transcript of A2: Analysis of Adverse Events - T Hunt (PHSA)
Analysis of Actions Following Adverse Patient Safety Events: Lessons Learned for Preventing Reoccurrence
Trish Hunt, BSN, MSc, CPHRMDirector, Risk Management
Jessica Jaiven, BSc, MSc, MPHProject Director
Quality, Safety & Outcome Improvement, Provincial Health Services Authority
Quality Forum March 8, 2012BC Patient Safety and Quality Council
Disclosure
• No conflicts to disclose
Outline
• PHSA overview• Purpose• Methodology• Results• Conclusions • Going forward• Key Take Away Messages
PHSA: Who we are…
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
Purpose
• In our efforts to be a highly reliable organization, we analyze reoccurring themes in our critical patient safety events (CPSERs) to help:
– Focus on recommendations/actions arising from CPSERs
– Review of the 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):
• level 4 and 5 (significant patient harm and/or death) • 2009—2011• n = 124 (CPSERs)• 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
Results
Results
Results
Results
Results
Summary of Dominant Themes
The 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
Summary of Dominant Themes
3. Education and Training – Examples:
• Assessment and diagnostics• Team members’ roles and responsibilities• Treatment/management and consultation for deteriorating patient conditions
Conclusions
• Themes are consistent with the level and complexity of care provided in tertiary/specialized care agencies and with the adverse events analysis/patient safety literature
• 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 framework, policy
• Continue to improve the CPSER process in PHSA– Leadership, patient safety and quality knowledge, 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• CCMs (Clinical care management) and protocols
• Combine different quality improvement and analysis methods
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
