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

2. Scenario One morning, Esther was being moved from her bed to a chair using a Hoyer-type lift. She called for a CNA to help her. One morning, Esther was being moved from her bed to a chair using a Hoyer-type lift. She called for a CNA to help her. As the CNA was moving her, Esther fell and suffered a serious head injury as well as some superficial scratches. As the CNA was moving her, Esther fell and suffered a serious head injury as well as some superficial scratches. Esther was briefly hospitalized for evaluation of her head injury; a CT showed no intracranial bleeding, and she was released the next day. Esther was briefly hospitalized for evaluation of her head injury; a CT showed no intracranial bleeding, and she was released the next day.

3. Scenario During an investigation following the fall, the CNA admitted that she did not follow the policy that required two staff members assist with all transfers. During an investigation following the fall, the CNA admitted that she did not follow the policy that required two staff members assist with all transfers. The investigation found that the CNA was not compliant with the facilitys policy for transfers. The investigation found that the CNA was not compliant with the facilitys policy for transfers. She was given a warning and re-trained on the importance of the policy. She was given a warning and re-trained on the importance of the policy.

4. How do we respond? Look for the individual who was at fault Look for the individual who was at fault Focus on training, compliance with policies Focus on training, compliance with policiesBUT….. What if it happens again? What if it happens again? What if someone else does the same thing? What if someone else does the same thing? What if it goes deeper than that? What if it goes deeper than that?

5. What is RCA? Root Cause Analysis Root Cause Analysis Structured way of looking at events from a systems perspective Structured way of looking at events from a systems perspective Events are rarely just the fault of one person doing the wrong thing Events are rarely just the fault of one person doing the wrong thing People operate in a system. The system can make it easier for them to do the right thing, or more difficult People operate in a system. The system can make it easier for them to do the right thing, or more difficult Have to look at multiple contributing factors Have to look at multiple contributing factors If you dont uncover all potential causes, event can happen again If you dont uncover all potential causes, event can happen again

6. What is RCA? Grew out of theories of accident analysis, systems design, safety engineering Grew out of theories of accident analysis, systems design, safety engineering Required by the Joint Commission in response to sentinel events Required by the Joint Commission in response to sentinel events Required by Veterans Administration Required by Veterans Administration Used primarily in hospitals, but starting to be used in some nursing homes Used primarily in hospitals, but starting to be used in some nursing homes OR, MD, some MN facilities OR, MD, some MN facilities Compatible with MDH regulatory role Compatible with MDH regulatory role

7. What is RCA? Facilitated Process Facilitated Process After event: gather documents, assemble basic timeline After event: gather documents, assemble basic timeline Assemble all players Assemble all players Draw out the story – from all perspectives Draw out the story – from all perspectives Work to identify contributing factors Work to identify contributing factors Why, why, why, why, why? Why, why, why, why, why? Develop plans of correction that address contributing factors Develop plans of correction that address contributing factors

8. Scenario One morning, Esther was being moved from her bed to a chair using a Hoyer lift. She called for a CNA to help her. One morning, Esther was being moved from her bed to a chair using a Hoyer lift. She called for a CNA to help her. As the CNA was moving her, Esther fell and suffered a serious head injury as well as some superficial scratches. As the CNA was moving her, Esther fell and suffered a serious head injury as well as some superficial scratches. Esther was briefly hospitalized for evaluation of her head injury; a CT showed no intracranial bleeding, and she was released the next day. Esther was briefly hospitalized for evaluation of her head injury; a CT showed no intracranial bleeding, and she was released the next day. Scenario source: Oregon Patient Safety Commission

9. Scenario An investigation after Esthers fall discovered the following: An investigation after Esthers fall discovered the following: The lift had been used many times before, and there were no known problems with it. The lift had been used many times before, and there were no known problems with it. There were two lifts on the floor, but one was already in use. There were two lifts on the floor, but one was already in use. Both lifts were older models that required two people to use correctly. Both lifts were older models that required two people to use correctly.

10. Scenario The CNA was aware of the policy requiring two people for transfers with Hoyer-type lifts. Before assisting Esther, she tried to find someone to help her. Of the two other CNAs on duty, both were busy helping other residents. The CNA was aware of the policy requiring two people for transfers with Hoyer-type lifts. Before assisting Esther, she tried to find someone to help her. Of the two other CNAs on duty, both were busy helping other residents. The CNA was running behind in her work, and she knew that Esther tended to get agitated if she had to wait very long to get help. The CNA was running behind in her work, and she knew that Esther tended to get agitated if she had to wait very long to get help.

11. Scenario The CNA had used this lift by herself before without incident; she believed that she could use it safely again, so she made a decision to do the transfer unassisted. The CNA had used this lift by herself before without incident; she believed that she could use it safely again, so she made a decision 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 to maneuver the lift around some obstacles in Esthers crowded room; this led to Esthers feet getting tangled in the lift, making her lose her balance. When she was transferring Esther, she had to maneuver the lift around some obstacles in Esthers crowded room; this led to Esthers feet getting tangled in the lift, making her lose her balance.

12. Scenario Contributing factors for Esthers fall: Contributing factors for Esthers fall: Environmental (crowded room, old lift) Environmental (crowded room, old lift) Staffing (other staff busy, no plan for getting assistance) Staffing (other staff busy, no plan for getting assistance) Policy (no provision for situations when backup not available) Policy (no provision for situations when backup not available) Culture (acceptance of shortcuts, individual vs team approach) Culture (acceptance of shortcuts, individual vs team approach)

13. Scenario Action Plan: Action Plan: Explore purchase of lifts that can be used by just one person, are more stable Explore purchase of lifts that can be used by just one person, are more stable Consider assistance with transfers when developing workplans/priorities for staff Consider assistance with transfers when developing workplans/priorities for staff Increased management follow-up to assess effectiveness of modified workplans Increased management follow-up to assess effectiveness of modified workplans Nurture team approach to care/less individualized focus on roles Nurture team approach to care/less individualized focus on roles

14. Two approaches Focus on individual errors Focus on individual errors Individual blame Individual blame Punishing errors Punishing errors Expectation of perfect performance Expectation of perfect performance Solutions tend to be disciplinary or focused on training Solutions tend to be disciplinary or focused on training Focus on conditions that allow errors to happen Focus on conditions that allow errors to happen Changing systems Changing systems Learning from errors Learning from errors Expectation of professional performance within a system that compensates for human limitations Expectation of professional performance within a system that compensates for human limitations Solutions might involve training, equipment, cultural change, staffing Solutions might involve training, equipment, cultural change, staffing

15. Whats in it for you? Enhanced engagement/ownership by staff Enhanced engagement/ownership by staff Empowers staff/Fosters creativity Empowers staff/Fosters creativity Process/systems focused Process/systems focused Fosters more in-depth analysis Fosters more in-depth analysis Assists you in completing the required Vulnerable Adult documentation/analysis Assists you in completing the required Vulnerable Adult documentation/analysis Risk prevention Risk prevention Staff are more proactive -Identify risks in environment Staff are more proactive -Identify risks in environment Culture Change – more awareness of resident safety and how staff can impact this Culture Change – more awareness of resident safety and how staff can impact this Non-punitive (Just Culture) Non-punitive (Just Culture)