ScenarioScenario

Esther, age 87, is a resident at a Esther, age 87, is a resident at a Minnesota nursing home. She has been Minnesota nursing home. She has been there for three years. She was able to there for three years. She was able to walk with a walker when she arrived, but walk with a walker when she arrived, but now needs a great deal of assistance now needs a great deal of assistance getting in and out of bed, and generally getting in and out of bed, and generally uses a wheelchair when out of her room.uses a wheelchair when out of her room.

Scenario source: Oregon Patient Safety Improvement Corps Team 2007/2008 in collaboration with community  and advocacy organizations

ScenarioScenario

One morning, Esther was being moved One morning, Esther was being moved from her bed to a chair using a Hoyer-type from her bed to a chair using a Hoyer-type lift. She called for a CNA to help her. lift. She called for a CNA to help her.

As the CNA was moving her, Esther fell As the CNA was moving her, Esther fell and suffered a serious head injury as well and suffered a serious head injury as well as some superficial scratches. as some superficial scratches.

Esther was briefly hospitalized for Esther was briefly hospitalized for evaluation of her head injury; a CT evaluation of her head injury; a CT showed no intracranial bleeding, and she showed no intracranial bleeding, and she was released the next day.was released the next day.

ScenarioScenario

During an investigation following the fall, During an investigation following the fall, the CNA admitted that she did not follow the CNA admitted that she did not follow the policy that required two staff members the policy that required two staff members assist with all transfers.assist with all transfers.

The investigation found that the CNA was The investigation found that the CNA was not compliant with the facility’s policy for not compliant with the facility’s policy for transfers. transfers.

She was given a warning and re-trained She was given a warning and re-trained on the importance of the policy.on the importance of the policy.

How do we respond?How do we respond?

Look for the individual who was at faultLook for the individual who was at fault Focus on training, compliance with policiesFocus on training, compliance with policies

BUT…..BUT….. What if it happens again?What if it happens again? What if someone else does the same What if someone else does the same

thing?thing? What if it goes deeper than that?What if it goes deeper than that?

What is RCA?What is RCA?

Root Cause AnalysisRoot Cause Analysis Structured way of looking at events from a Structured way of looking at events from a

systemssystems perspectiveperspective Events are rarely just the fault of one person doing Events are rarely just the fault of one person doing

the wrong thingthe wrong thing People operate in a system. The system can make it People operate in a system. The system can make it

easier for them to do the right thing, or more difficulteasier for them to do the right thing, or more difficult Have to look at multiple contributing factorsHave to look at multiple contributing factors If you don’t uncover all potential causes, event can If you don’t uncover all potential causes, event can

happen againhappen again

What is RCA?What is RCA?

Grew out of theories of accident analysis, Grew out of theories of accident analysis, systems design, safety engineeringsystems design, safety engineering

Required by the Joint Commission in Required by the Joint Commission in response to sentinel eventsresponse to sentinel events

Required by Veteran’s AdministrationRequired by Veteran’s Administration Used primarily in hospitals, but starting to Used primarily in hospitals, but starting to

be used in some nursing homesbe used in some nursing homes OR, MD, some MN facilitiesOR, MD, some MN facilities

Compatible with MDH regulatory roleCompatible with MDH regulatory role

What is RCA?What is RCA?

Facilitated ProcessFacilitated Process After event: gather documents, assemble After event: gather documents, assemble

basic timelinebasic timeline Assemble all playersAssemble all players Draw out the story – from all perspectivesDraw out the story – from all perspectives Work to identify contributing factorsWork to identify contributing factors

Why, why, why, why, why?Why, why, why, why, why? Develop plans of correction that address Develop plans of correction that address

contributing factorscontributing factors

ScenarioScenario

One morning, Esther was being moved One morning, Esther was being moved from her bed to a chair using a Hoyer lift. from her bed to a chair using a Hoyer lift. She called for a CNA to help her. She called for a CNA to help her.

As the CNA was moving her, Esther fell As the CNA was moving her, Esther fell and suffered a serious head injury as well and suffered a serious head injury as well as some superficial scratches. as some superficial scratches.

Esther was briefly hospitalized for Esther was briefly hospitalized for evaluation of her head injury; a CT evaluation of her head injury; a CT showed no intracranial bleeding, and she showed no intracranial bleeding, and she was released the next day.was released the next day.

Scenario source: Oregon Patient Safety Commission

ScenarioScenario

An investigation after Esther’s fall An investigation after Esther’s fall discovered the following:discovered the following:

The lift had been used many times before, The lift had been used many times before, and there were no known problems with it.and there were no known problems with it.

There were two lifts on the floor, but one There were two lifts on the floor, but one was already in use. was already in use.

Both lifts were older models that required Both lifts were older models that required two people to use correctly.two people to use correctly.

ScenarioScenario

The CNA was aware of the policy requiring The CNA was aware of the policy requiring two people for transfers with Hoyer-type two people for transfers with Hoyer-type lifts. Before assisting Esther, she tried to lifts. Before assisting Esther, she tried to find someone to help her. Of the two other find someone to help her. Of the two other CNA’s on duty, both were busy helping CNA’s on duty, both were busy helping other residents.other residents.

The CNA was running behind in her work, The CNA was running behind in her work, and she knew that Esther tended to get and she knew that Esther tended to get agitated if she had to wait very long to get agitated if she had to wait very long to get help. help.

ScenarioScenario

The CNA had used this lift by herself before The CNA had used this lift by herself before without incident; she believed that she could without incident; she believed that she could use it safely again, so she made a decision use it safely again, so she made a decision to do the transfer unassisted.to do the transfer unassisted.

The CNA was trained in how to use the lift.The CNA was trained in how to use the lift. When she was transferring Esther, she had When she was transferring Esther, she had

to maneuver the lift around some obstacles to maneuver the lift around some obstacles in Esther’s crowded room; this led to in Esther’s crowded room; this led to Esther’s feet getting tangled in the lift, Esther’s feet getting tangled in the lift, making her lose her balance.making her lose her balance.

ScenarioScenario

Contributing factors for Esther’s fall:Contributing factors for Esther’s fall: Environmental (crowded room, old lift)Environmental (crowded room, old lift) Staffing (other staff busy, no plan for getting Staffing (other staff busy, no plan for getting

assistance)assistance) Policy (no provision for situations when Policy (no provision for situations when

backup not available)backup not available) Culture (acceptance of shortcuts, individual vs Culture (acceptance of shortcuts, individual vs

team approach)team approach)

ScenarioScenario

Action Plan:Action Plan: Explore purchase of lifts that can be used by Explore purchase of lifts that can be used by

just one person, are more stablejust one person, are more stable Consider assistance with transfers when Consider assistance with transfers when

developing workplans/priorities for staffdeveloping workplans/priorities for staff Increased management follow-up to assess Increased management follow-up to assess

effectiveness of modified workplanseffectiveness of modified workplans Nurture team approach to care/less Nurture team approach to care/less

individualized focus on rolesindividualized focus on roles

Two approachesTwo approaches

Focus on individual errorsFocus on individual errors

Individual blameIndividual blame

Punishing errorsPunishing errors

Expectation of perfect Expectation of perfect performanceperformance

Solutions tend to be Solutions tend to be disciplinary or focused on disciplinary or focused on trainingtraining

Focus on conditions that Focus on conditions that allow errors to happenallow errors to happen

Changing systemsChanging systems Learning from errorsLearning from errors

Expectation of professional Expectation of professional performance within a system performance within a system that compensates for human that compensates for human limitationslimitations

Solutions might involve Solutions might involve training, equipment, cultural training, equipment, cultural change, staffingchange, staffing

What’s in it for you?What’s in it for you? Enhanced engagement/ownership by staffEnhanced engagement/ownership by staff

Empowers staff/Fosters creativityEmpowers staff/Fosters creativity

Process/systems focused Process/systems focused

Fosters more in-depth analysisFosters more in-depth analysis Assists you in completing the required Vulnerable Adult Assists you in completing the required Vulnerable Adult

documentation/analysisdocumentation/analysis

Risk preventionRisk prevention Staff are more proactive -Identify risks in environment Staff are more proactive -Identify risks in environment

Culture Change – more awareness of resident safety Culture Change – more awareness of resident safety and how staff can impact thisand how staff can impact this

Non-punitive (Just Culture)Non-punitive (Just Culture)