Module 4: Comprehensive analysis method
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The document outlines a comprehensive incident analysis learning program, focusing on methodologies for reviewing healthcare incidents to improve patient safety. It highlights the steps involved in conducting thorough investigations, the importance of understanding contributing factors, and using diagramming tools to analyze incidents. The training emphasizes an interdisciplinary approach and effective communication to foster a culture of safety and learning in healthcare settings.
Module 4: Comprehensive analysis method
- 1. Incident Analysis Learning Program - Module Four Comprehensive Analysis Method Jan. 10, 2013
- 2. Welcome Ioana Popescu Sandi Kossey Erin Pollock Tina Cullimore
- 3. Learning Program M3 WHAT WAS LEARNED? WHAT CAN BE DONE? HOW AND WHY? WHAT HAPPENED?
- 4. Analysis Methods • Canadian Incident Analysis Framework • Systematic Systems Analysis • Local framework • Other (VA, NPSA)
- 5. 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
- 6. Agenda 3-parts • Knowledge expert • Practice leader • Facilitated discussion
- 7. Introducing: WebEx Be prepared to use: - Raise Hand & Checkmark - Chat & Q&A - Pointer & Text 7 11-Jan-13 7
- 8. About You M2
- 10. 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.
- 11. Individual Perspectives to M2 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.
- 14. 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.
- 15. 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
- 16. 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
- 17. Create a Detailed Timeline Example (p.104)
- 18. 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.
- 19. HOW AND WHY IT HAPPENED? • Analyze information to identify contributing factors and relationships • Uses systems theory and human factors • Uses diagramming • Summarizes findings
- 20. 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?
- 21. 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
- 22. 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.
- 26. 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
- 28. Guiding Questions Appendix G (p. 89) Example
- 29. 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
- 30. 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”
- 31. 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
- 32. Ultimate Goal To WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER
- 33. 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
- 34. Real-life Experience Dr. Chris Hayes
- 35. Incident Analysis Framework: Real-life Experience Module 4: Comprehensive analysis method January 10, 2013
- 36. 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
- 37. What is critical incident (ie. a severe harmful patient safety incident) • Not factored into event that occurs when a Any unintended the definition at St. patient receives treatment in the hospital, Michael’s – perspective of patient outcome is considered – that results in death, or serious disability, first….harm feels like harm!! injury or harm to the patient, and – assumes inherent risks are fixed with no – potential in learning or reducing…eg CLI does not result primarily from the patients' – data supports inherent risk of or fromd/t known underlying medical condition death a adverse events providing the treatment risk inherent in = 1/116
- 38. 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.
- 39. 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
- 40. 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
- 42. 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 Patient record, confirmed by ordered Dilantin 1g over 20 min resident interview 23:55 Nurse finished preparing, hung and administered Patient record, confirmed by Dilantin nurse interview Jan 2, 12 00:20 Patient blood pressure noted at 230/120, requring Patient record more oxygen 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
- 44. Conducting the analysis Verbal order Acute issue, middle of given night Patient suffers large MI and CHF following wrong drug administration Nurse had to Double-check policy Sound-alike, look leave bedside to does not include alike drugs stored prepare med anticonvulsants together
- 46. “Swiss Cheese” model Medication Manufacturer organization Hazards Sound-alike look-alike drug Purchasing Losses CHF/MI RN/MD Double-check
- 48. What did we do?
- 49. What did we do?
- 50. 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
- 52. 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
- 53. Case Study – Virtual Group Exercise
- 54. Breakout Session 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”
- 55. Small Group Discussion 0 Experience with comprehensive analysis 10 - 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
- 57. Wrap-up
- 58. 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
- 59. Resource slide Learning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningP rogram/Pages/Session-Recordings-and-Documents.aspx HQCA’s Systematic Systems Analysis http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Revi ews%20FINAL%20June%202012.pdf Incident Analysis Tools http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnal ysis/Pages/Tools.aspx
- 60. Mulţumesc Thank You