Patient safety and incident management

P bar Y Safety Consultants Alberta Canada

Patient Safety and Incident Management

What things you need to talks about for better care and worker safety


The critical 3 to your plan

• Incident management—the actions that follow patient safety incidents (including near misses)

• Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring

• System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources).



You need to know your lead and lags before you can help the patient(s)


Outcome Definitions

•Clinical incident: An event or circumstance which could have or did harm a patient

•Near miss: An incident which did not reach a patient

•No-harm incident: An incident which reached the patient but did not cause harm

•Adverse event: An incident that harmed a patient

Clinical incidents = Near misses (90%) + Adverse events (10%)


Adverse events happen

• Think about an incident you were involved in

• What happened?

• What was the error?

• What happened next?

Think more about the facts, not how it felt. We will be dealing with the feelings and emotions later in the session


Open disclosure = open communication

Open Disclosure refers to open communication when things go wrong in health care and include:

1. An expression of regret;

2. A factual explanation of what happened;

3. Consequences of the event; and

4. Steps being taken to manage the event and prevent a recurrence.


How does incident reporting lead to improved patient safety?

Clinical I ncident

RecogniseI ncident

Notif y I ncident

I ncidentAnalysis

Local Corrective

Actions

System wide

corrective actions

PATI ENT EXPERI ENCE


IM

• Incident Management or IM Resources to guide the immediate and ongoing actions following a patient safety incident (including near misses). We emphasize immediate response, disclosure, how to prepare for analysis, the analysis process, follow-through, how to close the loop and share learning.


PS

Patient safety management: Resources to guide action before the incident (e.g., plan, anticipate, and monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. We promote a patient safety culture and reporting and learning system.


SF

System factors: Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.


Thing you need to consider in your programs

• Patient- and family-centred care. The patient and family are at the centre of all patient safety and incident management activities. Engage with patients and families throughout their care processes, as they are an equal partner and essential to the design, implementation, and evaluation of care and services.

• Safety culture. Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system's structures and control mechanisms to produce behavioural norms. An organization with a safety culture avoids, prevents, and mitigates patient safety risks at all levels. This includes a reporting and learning culture.

• System perspective. Keep patients safe by understanding and addressing the factors that contribute to an incident at all system levels, redesigning systems, and applying human factor principles. Develop the capability and capacity for effectively assessing the complex system to accurately identify weaknesses and strengths for preventing future incidents.

• Shared responsibilities. Teamwork is necessary for safe patient care, particularly at transitions in care. It is the best defence against system failures and should be actively fostered by all team members, including patients and families. In a functional teamwork environment, everyone is valued, empowered, and responsible for taking action to prevent patient safety incidents, including speaking up when they see practices that endanger safety.


Unsafe acts are like mosquitoes…

You can try to swat them one at a time, but there will always be others to take their place. The only effective remedy is to drain the swamps in which they breed. In the case of errors and violations, the "swamps" are equipment designs that promote operator error, bad communications, high workloads, budgetary and commercial pressures…


Safety = absence of errors?

• Multiple dimensions– an outlook: health care is complex and risky and solutions

are found in the broader systems context;– a set of processes: identify, evaluate, and minimize hazards

and continuously improve– an outcome: manifested by fewer medical errors and

minimized risk or hazard


Active vs. latent error

• Active errors – occur at the level of the frontline operator– their effects are felt almost immediately

• Latent errors – removed from the direct control of the operator – poor design, incorrect installation, faulty

maintenance, bad management decisions, and poorly structured organizations


High reliability theory

• accidents can be prevented through good organizational design and management– an organizational commitment to safety– high levels of redundancy in personnel and safety

measures– strong organizational culture for continuous

learning and willingness to change


Talking a new language in Safety• Actions (taken to reduce risk of harm): Actions taken to reduce, manage,

or control any future harm, or probability of harm.• Alerts or advisories: An alert or advisory is a piece of information that has

been produced and publicly posted that outlines a specific type of patient safety incident or series of incidents that did occur or could occur.

• Authority gradient: Balance of decision-making power or the steepness of command and hierarchy in a given situation.

• Contributing factors: A circumstance, action or influence which is thought to have played a part in the origin or development of an incident or to increase the risk of an incident.

• Culture, Patient Safety: Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system’s structures and control mechanisms to produce behavioural norms.


The single person vs. the all the patients


Breaking A No-Win Cycle• Serious clinical adverse event occurs.• Organization is not transparent. • People close to the incident contact media.• Media contacts the organization, gets “no comment,” or

incorrect or superficial information.• Media go looking everywhere for any information.• Information is supplied by people who really don’t know.• All parties are further traumatized by the strident, inaccurate

media attention. • The organization’s response becomes as big a story.


Serious Clinical Event Defined

• Serious harm, potential serious harm, death, or a clear or present danger to one or more patients and/or to a community (psychological and physical)

• Possible definitions include but not limited to:– Harm categories G, H, and I, as measured by the NCC MERP

harm index. – Sentinel events as defined by Joint Commission– The National Quality Forum Serious Reportable Events as a

baseline list of serious clinical events. – HPI Safety Event Classification .

• Harm is usually, but not exclusively, preventable.


Crisis Management Team:Moving Forward

• Routine check-in daily to multiple times a day• Maintain highly disciplined documentation and log• Engage outside help through colleagues and consultants• Listen and be prepared to hear things you don’t want to• Embrace speed and flexibility• Stay close to internal and external voices• Consider implications for hospital/professional billing • Imagine the worst; mitigate as possible• Be prepared for inquiry from or the arrival of external

accrediting and regulatory agencies• Ensure knowledge management / improvement


Crisis Management Plan

• Internal notifications• Crisis Management Team• Priorities

– Patient and family– Staff– Organization

• External and Internal Communications• External notifications and unannounced visits


Areas Requiring Focus(In this order)

1. Patient and family2. Staff, particularly those at the sharp

end of the error3. Organization


Seeking To Achieve for AllPatient, Family, Staff, Organization

• Empathy• Disclosure• Support (including reimbursement)• Assessment• Apology• Resolution (including compensation)• Learning• Improvement


The new and now world of patients• Harm: Impairment of structure or function of the body and/or any

deleterious effect arising therefrom. Harm includes disease, injury, suffering, disability and death.

• Hazard: Situations with the potential to cause harm.• Healthcare organization: An organization that provides health services in

any healthcare sector.• High Reliability Organizations (HROs): Organisations that have few

accidents despite operating in highly dynamic, technologically rich and hazardous industries.

• Human Factors: A discipline addressing human behaviour, abilities, limitations, and relationship to the work environment (physical, organizational, cultural), with the goal to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems..


In your program in their lives

• Incident Analysis: A structured process that aims to identify what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It is also referred to as system based analysis.

• Incident Management: The various actions and process required to conduct the immediate and ongoing activities following an incident. Incident analysis is a component of incident management.


This world is all about the PatientPatient safety incident: An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. There are three types of patient safety incidents:• Harmful incident: A patient safety incident that resulted in harm

to the patient. Replaces "preventable adverse event”• Near miss: A patient safety incident that did not reach the patient

and therefore no harm resulted.• No-harm incident: A patient safety incident that reached the

patient but no discernible harm resulted.Patient safety: The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes.


Tools and skills for safety• Prospective analysis: An analytical tool to assess and mitigate harm or

loss by analyzing a situation or process that carries with it some inherent risk. Its purpose is to identify the way in which a process might potentially fail, with the goal to eliminate or reduce the likelihood or outcome severity of such a failure.

• Providers: Refers to physicians, professional, unregulated staff, and others engaged in the delivery of health services.

• Quality Improvement (QI): A formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used.

• Resilience: The degree to which a system continuously prevents, detects, mitigates or ameliorates hazards or incidents so that an organization can “bounce back” to its original ability to provide core functions.


Your risk management is people first

• Risk management: An organized effort to identify, assess and reduce, where appropriate, risks to patients, visitors, staff and organizational assets. Activities are undertaken to identify, analyze and educate, and to structure processes to reduce the likelihood of adverse events.

• Risk mitigation: The process of identifying and implementing precautions or controls that will most effectively reduce the consequence or likelihood of occurrence of a risk.


Patient care is TEAM event not a manual

Team: Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/objective/ mission. Patients/families are part of the team.


Role of professionals

• Become active leaders in encouraging and demanding improvements in patient safety.

• Setting standards, convening and communicating with members about safety

• Incorporating attention to patient safety into training programs

• Collaborating across disciplines• Contribute to creating a culture of safety. As patient

advocates, health care professionals owe their patients nothing less.


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Patient safety and incident management