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Focused Review of a Sentinel Event Root Cause Analysis.

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Presentation on theme: "Focused Review of a Sentinel Event Root Cause Analysis."— Presentation transcript:

1 Focused Review of a Sentinel Event Root Cause Analysis

2 Determination the Need for Focused Review When something goes wrong, the appropriate clinical experts are in consultation –Administration –Physician leadership –Nursing leadership –Risk Management –Quality Management

3 Determination of Need for Focused Review continued It is determined that the event meets the definition for sentinel events –NQF 27 Adverse Event Criteria –JCAHO Minimum Criteria The event is a near miss (good catch) –the event has resulted or could have resulted in patient harm Problems keep repeating

4 Surgical Events Product or Device Events Patient Protection Events Care Management Events Environmental Events Criminal Events NQF Adverse Events

5 Events resulting in an unanticipated death or major permanent loss of function, not related to the natural course of the patients illness or underlying condition JCAHO Minimum Events

6 Event is one of the following (even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patients illness or underlying condition) –Suicide of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge –Unanticipated death of a full-term infant –Abduction of any individual receiving care, treatment or services –Discharge of an infant to the wrong family –Rape –Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities –Surgery on the wrong individual or wrong body part –Unintended retention of a foreign object in an individual after surgery or other procedure JCAHO Minimum Events

7 Unanticipated death or major permanent loss of function associated with a health care- acquired infection Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter) Prolonged fluoroscopy with cumulative dose >1500 rads to a single field, or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose JCAHO Minimum Events

8 Near Misses Repeated problems Events which have resulted in patient harm, or could have resulted in patient harm –Risk thereof Other events where RCA could be considered

9 Assists to prioritize safety related problems Applies resources (time) where they have the greatest opportunity to improve safety A tool intended to prioritize safety events yet not take the place of judgment Based on 2 dimensions Safety Assessment Code

10 Severity : Based on actual and potential risk – worst case Needs to have consistent definition Should be determined first

11 Safety Assessment Code Catastrophic –Death or major permanent loss of function not related to natural course of illness or underlying condition Major –Permanent lessening of bodily function not related to natural course of illness or underlying condition Moderate –Increased length of stay or level of care Minor –No injury, no increased length of stay or level of care

12 Safety Assessment Code Probability : More subjective, greater chance of variation Should be reflective of the facility Categories –Frequent –Occasional –Uncommon –Remote

13 Safety Assessment Matrix SEVERITY CatastrophicMajorModerateMinor Frequent 3321 Occasional 3211 Uncommon 3211 Remote 3211 Frequency Adapted from:

14 Sentinel Event Focused Review Algorithm It is determined that a focused review should be conducted The action plan is facilitated by the manager RCA documents are reviewed by medical staff in the Department Meeting (includes action plan) Manager schedules the RCA to be conducted within 30 days of the event The RCA is conducted and an action plan is established Measurement plan is implemented; the action plan is evaluated for effectiveness

15 Participating in a RCA is an opportunity to learn Opportunity for staff to tell their story Emphasis is on improving the system and not correcting the individuals Root Cause Analysis

16 Systematic process for identifying the most basic causal factor or factors for an undesirable event or problem Focus is on process and systems, not individuals Frequently ask why Confidential Conduct within 45 days Root Cause Analysis

17 Who What When Where Why

18 Mechanism for reporting Sentinel Events Investigating and evaluating causative factors Initiation of performance improvement Action plan development to prevent recurrence Goals of a Root Cause Analysis

19 Understand the sequence of events –Flow chart –Cause and Effect Diagram Chronological details can be done before to save time Reviewing literature can help the team to differentiate between what they may or may not have within their control

20 Multidisciplinary : –Key staff and departments directly and indirectly involved in the event –Physicians, nurses and managers –Performance Improvement Staff RCA Team

21 CONFIDENTIAL Safe protected environment Quality Management v.s. Risk Management Gain better insight into processes involved in the event –Frequently asks why Peer Review –MN Statute §§ 145.61 QM acts as a facilitator Key Aspects

22 Details of the event Human factors Staffing Communication Education Equipment Environmental Uncontrollable external factors Other factors Key Elements of RCA

23 Helps team understand event Assures thoroughness of investigation –Human factors/Communication –Human factors/Training –Human factors fatigue/scheduling –Environment/Equipment –Rules/Policies/Procedures –Barriers Triage Questions


25 Root Cause Analysis Summary Root Cause Analysis Corrective Action Plan Confidential under MN Statute §§ 145.61 RCA Reporting Tools

26 To be thorough, a RCA must include: –Determination of human and other factors –Determine related processes and systems –Analysis of underlying causes and effects – series of whys –Identification of risks and their potential contributions Root Cause Analysis Summary

27 5 Rules of Causation –Causal statements must clearly show the cause and effect relationship –Negative descriptors are not used in a causal statement –Each human error must have a preceding cause –Each procedural deviation must have a preceding cause –Failure to act is only causal when there was a pre-existing duty to act Determining the Root Cause




31 Questions?

32 Focused Review of a Sentinel Event Developing a Corrective Action Plan

33 Historically the weakest link to the process Often RCA teams conclude solutions based on: –Recognition of warning signs –Training/education –Asking clinicians to be more careful Creates challenges for the RCA team Corrective Action Plan

34 Strong actions : –Physical plant changes –New device with usability testing prior to purchase –Forcing functions –Simplifying process – remove unnecessary steps –Standardize process/equipment –Leadership is actively involved Corrective Action Plan

35 Intermediate actions: –Decrease workload –Software enhancements/modifications –Eliminate/reduce distraction –Checklists/cognitive aids/triggers/prompts –Eliminate look alike and sound alike –Read back –Enhanced documentation/communication –redundancy

36 Corrective Action Plan Weak actions: –Double checks –Warnings/labels –New policies/procedures/memorandums –Training/education –Additional study

37 Do the Actions meet the following: –Address the root cause and contributing factors –Specific –Easily understood and implemented –Developed by process owners –Measurable Corrective Action Plan

38 Identifies opportunities for improvement Assigns responsibility for actions Target dates are set for completion Looks at follow up for effectiveness by using a measurement plan Corrective Action Plan

39 Why Measure? Confirmation that what we wanted to accomplish did in fact occur Measures effectiveness of action, not the completion of the action All improvement will require change, but not all change will result in improvement G. Langley, et al In God we trust. All other bring data W.E Deming Measure of Effectiveness

40 How will we know that the change results in improvement? Measurement answers the question Quality improvement measurement is for learning, not judgment, not research All measures have limitations Measurement should be used to guide improvement and test changes Focus on the changes made in the action plans

41 What to Measure Outcome Measures Reflect cumulative impact of multiple processes Big picture –Are we doing the right thing –Are we getting the results we want –Did we influence the health of the patient Reflect the health state of a patient resulting from our care Further investigation is needed to understand what processes need to be changed Outcome Measures How many falls on this unit? How many pressure ulcers occurred on this unit? How many wrong site surgery events did we have? How many medication errors occurred on this unit

42 What to Measure Process Measures Reflect current condition of our processes –Are they still working for us –Are we using them –Are we using the accurately Determine if processes are functioning effectively and efficiently Used to assess adherence to recommendations in clinical practice Able to identify specific areas of care that may require improvement Process Measures How many patients had the tool to assess for risk of falls How many patients with a Braden score of 6 had a WOC nurse consult How many times was the pause for cause observed correctly How many nurses matched the patients ID band to the MAR

43 How to Measure Complex and untimely Chart abstraction Financial reports Data obtained from existing databases and systems Guide change, indicate progress, timely Tally sheets Checklists Questionnaires Feedback interviews Observation Daily reviews

44 Measurement Plan Measures effectiveness of action, not the completion of the action Defined numerator/denominator Defined sampling plan and time frame Realistic performance threshold Plan for when initial measure did not meet threshold Measure of Effectiveness

45 Measurement Plan Examples % patients with risk assessment tool used – Randomly sample 10 patients/month for 3 months. If goal of 90% not reached, discuss with staff to determine barriers and make necessary changes, then re-audit. % Pause for Cause observed to be correctly done by OR staff – Randomly observe 10 surgeries/month for 3 months. If goal of 90% not reached, discuss with staff to determine barriers and make necessary changes, then re- audit. Measure of Effectiveness

46 Share with staff and Administration –Need to go beyond share at staff meeting - action is not sustained Collaborate with other units and sites Report sent to Medical Department for review/comments Spread the Success/knowledge


48 ACTION PLAN OWNER(s): HealthEast Root Cause Analysis IMPROVEMENT ACTION PLAN Opportunity to ImproveAction Rating ActionResponsible Person Target Date For Implementati on Completi on Date Initials Measures Follow-up for Effectiveness

49 Questions?

50 Thank You! Rosemary Emmons RN,BSN HealthEast Quality Management 651-232-3392 phone 651-864-2535 pager 651-232-4435 fax


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