Never Events and other serious adverse...Never Events and other serious adverse incidents Sally...
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Never Events and other serious adverse incidents Sally McCarthy Clinical Director Emergency Care Institute July 2015 Jacqui Irvine Co-Chair, Incident Advisory Committee Emergency Care Institute July 2015 Anne hawkind Co-Chair, Incident Advisory Committee Emergency Care Institute July 2015 ED Leadership Forum 31 July 2015
Transcript of Never Events and other serious adverse...Never Events and other serious adverse incidents Sally...
Never Events and other serious adverse
incidents
Sally McCarthy Clinical Director Emergency Care Institute July 2015
Jacqui Irvine Co-Chair, Incident Advisory Committee Emergency Care Institute July 2015
Anne hawkind Co-Chair, Incident Advisory Committee Emergency Care Institute July 2015
ED Leadership Forum 31 July 2015
“The ED environment has unique operating characteristics that
predispose it to error”
Croskerry, P. Cognitive forcing strategies in clinical decisionmaking. Annals of Emergency Medicine, 2003. 41 (1): pp. 110-120.
The “system” is important too “...a patient safety incident cannot simply be linked to the
actions of the individual healthcare staff involved. All incidents are also linked to the system in which the individuals were working.
Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring.”
National Patient Safety Agency, ‘Seven Steps to Patient Safety’’, 2004 – 2009. Available
at http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/
What are “never” events? the "kind of mistake that should never happen" in the field of medical treatment
(Wikipaedia) Kenneth Kizer coined the term "never events" while leading the US
National Quality Forum. Kizer asserts that using the negative carries an extra psychological charge.
Also, echoes Kahneman and Tversky's Nobel prize winning
research on "negative framing" which suggests that humans are more strongly inclined to take action when the actions in question are labeled so as to convey the loss avoided (rather than the benefit gained) and when the consequences of failing to act are mentally vivid
Simple Definition To be a never event, an incident must fulfil the following
criteria: • It has clear potential for, or has caused severe harm or
death. • There is evidence that it has occurred in the past (ie, it is a
known source of risk). • There is existing national guidance or safety
recommendations on how it can be prevented and there is support for implementing these.
• It can be easily defined, identified and continually measured.
Why so important? Never Events are key indicators that there have been failures
to put in place the required systemic barriers to error and their occurrence can tell something fundamental about the
quality, care and safety processes in an organisation.
Is this an ED “never event”?
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Is it time we thought about “never events” in the ED and focus on working to eliminate them?
Testicular torsion IIMS database 2010, 2013, 2014, Case 1: 19 year male, sudden onset testicular pain Triaged as testicular pain and distress. MO requested CTKUB; no scrotal exam ~ 6 hour delay to OT, likely non-viable
testis Outcome: MO states he made a mistake in not considering torsion Case 2: 15 year old young man, presented with testicular pain and swelling, TC 3, SB MO 1hr and 10mins later, US ordered US done almost 2 hours hrs later: no blood flow; surg reg paged 30 mins later Possible non-viable testis at OT Outcome: wrong TC; failure to notify surgical team immediately; delayed
ED MO initial assessment and wrong prioritisation of US above surgical r/v
Cont: Case 3: 13 year old boy, delayed but typical presentation of torsion referred by
GP to ED. TC 2, seen by MO within 6 mins and transfer arranged to referral hospital by ambulance. Delay in ambulance, testis non-viable at surgery.
Outcome: local GP not aware no acute surgery at local hospital; also, would private car be quicker than ambulance for transfer?
Case 4: 10 year old boy, sudden onset testicular pain and swelling some hours
prior to ED presentation. TC 4, not alerted to MO Prolonged wait in ED, once seen care expedited and appropriate Outcome: Poor triage assessment skills and failure at triage to recognise
a surgical emergency Case 5: presented with testicular pain and h/o torsion. Given TC 3 and sat in
WR Outcome: lack of appropriate recognition of emergency presentation
Cont.. Case 6: 14 year old male delayed presentation, delayed initial triage, delay to
MO assessment, delay while surgical and urology services refused to accept care of this age of patient. Subsequent transfer for surgery, over 6 hours from presentation. OT: necrotic testis
Outcome: surgeon referred to medical peer review Case 7: 14 year boy, provisional diagnosis of appendicitis by GP, then ED RMO
and surgical MO. VMO agreed over the phone with plan to manage as for appendicitis and transfer for surgery. No-one examined the scrotum.
At OT: non-viable testis Outcome: surgical registrar counseled. Case 8: young man, typical presentation with “acute testicular and R iliac fossa
pain”. TC 4, prolonged wait. After many hours waiting in ED waiting room, he left and returned the next day. At OT: non-viable testis
Outcome: no “root cause” found
Cont… Case 9: 23 year old, testicular pain. SB EDMO, bedside US performed, told
patient: “infection”. Subsequent episodes of pain and delayed presentation finally went to OT: non-viable testis
Outcome: torsion may have been there on first presentation; question of appropriate US credentialling of EDMO
Case 10: acute onset of testicular torsion referred to ED by LMO who called
the hospital admitting officer, and patient arrived 30mins later. Delay to be seen, US ordered, delay to OT from presentation of around 6 hours. OT: non-viable testis.
Outcome: criticism of lack of urgency by hospital in face of surgical emergency
And there are other similar incidents…
Themes identified in torsion incidents 1. Lack of recognition at triage of potential surgical
emergency: • Wrong TC allocated • MO not notified • Allowed prolonged wait in ED waiting room
2. Inadequate physical examination • Scrotum and testes not examined • Bedside US interpretation inadequate
3. US inappropriately prioritised over surgery 4. Lack of allocated surgical responsibility 5. Transfer delays 6. GP not aware of local hospital services
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T (02) 9464 4674 F (02) 9464 4728
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What is needed?
Management Suggestions • < 6 hours – can be saved so time critical • >12 hours and no flow on USS – cannot be saved so not
time critical HIGH RISK LOW RISK INT RISK Age 12-25yo Other age 12-25yo Sexually Active? No Either Yes PLAN Straight to
theatre, USS will not change plan
Further IXN: - Cremasteric
reflex - Urine dip - USS
Further IXN: - Cremasteric
reflex - Urine dip - USS
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Unless there are positive findings of an alternative diagnosis then treat as torsion! 1:20 False Negative at Theatre and low risk procedure. Loss of testicular function is a much higher risk.
Level 4, Sage Building, 67 Albert Avenue Chatswood, NSW 2067
T (02) 9464 4674 F (02) 9464 4728
www.ecinsw.com.au
What system changes are required? • System that identifies testicular
pain as time critical • Triage 2 • Torsion is diagnosis of exclusion
and current methods DO NOT reliably exclude it
• Usual management is theatre and USS should not delay this.
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Know your LOCAL procedures… You may need to write one.
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What might be ED “never events”?
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Definition This definition is from the UK*, however, never events have
been defined in other health systems, and all are similar *Revised Never Events Policy and Framework
NHS England Patient Safety Domain 27 March 2015
Never Events are a particular type of serious incident that
meet all the following criteria: • They are wholly preventable, where guidance or safety
recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.
Definition Each Never Event type has the potential to cause serious patient
harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event.
There is evidence that the category of Never Event has occurred in
the past, for example through reports to the National Reporting and Learning System (NRLS), and a risk of recurrence remains.
Occurrence of the Never Event is easily recognised and clearly
defined – this requirement helps minimise disputes around classification, and ensures focus on learning and improving patient safety.
Implications for hospitals… “It goes without saying that a patient who is a victim of a never
event should not have to pay for it.” Therefore, hospitals determine on a case-by-case basis which
costs are directly related to the never event and waive those costs so that the patient and no third-party payer receives a bill for those costs.
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What has happened as a result?
June 2014: some progress
