Presentation on theme: "Sentinel events and near miss reporting, analysis and prevention"— Presentation transcript:
1 Sentinel events and near miss reporting, analysis and prevention The Good Hospital Practice Training Series 2009The Medical City
2 All hospitals have sentinel events. The difference between an excellent hospital and a poor one is that the excellent hospital continuously tries to improve its systems and processes to understand and eventually reduce the number of its sentinel events.
3 There is no denying it: Health care kills patients!
4 Why should we make our hospital practice safer? Becauseour reputation,our earnings, andour continued credentialing and privileging depend on the quality and safety of our medical practice.And because the well-being and the lives of our patients depend on safe and high quality care..
5 The JCI Sentinel Events Policy Goals To improve patient care, treatment and services and prevent sentinel eventsTo focus organizational attention to a sentinel event’s root causes and change systems and processes to prevent its recurrenceTo increase general knowledge of sentinel events, their causes and prevention through data collectionTo maintain public confidence in accreditation
6 What is a sentinel event? An unexpected occurrence involving death, physical or psychological injury or the risk thereof (any process variation for which recurrence carries a significant risk of a serious adverse outcome)Sentinel means a signal for immediate investigation and responseSentinel event is not the same as medical error. Patients may experience sentinel events as part of their disease process or high-risk treatments. Even if some error has occurred, it may not have caused the sentinel event.But sentinel events can result from errors of omission or commission
7 The Medical City List of Sentinel Events Death / paralysis following surgeryDeath / paralysis of mother/infant undergoing deliveryRetained surgical instruments / materialsSurgery on wrong body part / wrong patientPatient fall resulting in death / paralysisSerious adverse drug reactions involving DrugWatch list drugsMajor blood transfusion reaction
8 DRUGWATCH LIST Be careful in using these drugs! DobutamineHeparinWarfarin (Coumadin)InsulinPotassium chlorideMagnesium sulfateCalcium gluconateSodium bicabonateLidocaineDopamine
9 The Medical City list of adverse events 1. Infection control indicators1.1 hospital care related infections (ventilator associated pneumonia, Foley catheter associated UTI, blood stream infections from central venous lines, surgical site infections)1.2 needlestick injuries2. Heel hematoma after blood extraction in neonates3. Self-extubation in intubated patients4. Unanticipated death, cardiorespiratory arrest or loss of major function in any admitted patient5. Unplanned re-admission into the hospital, ICU, NICU or OR6. Deaths from the following conditions6.1 Acute myocardial infarction6.2 Congestive heart failure6.3 Gastrointestinal hemorrhage6.4 Hip fracture6.5 Pneumonia6.6 Stroke7. Surgical incidents7.1 Postoperative hemorrhage or hematoma7.2 Postoperative infection (localized and systemic)8. Aspiration incidents in patients on tube feeding
10 When do you reportActual Event - when a sentinel event or adverse event actually happensNear Miss Events – when a sentinel event almost happened but was caught in the nick of time; a process deviation that did not affect outcome, but a recurrence carries significant chance of a serious adverse outcomeUnsafe Conditions – that might predispose to the sentinel event, includingMedical Device IssuesMedical Care issuesNursing Care issues
11 When do you report For example, for medication incident Actual Event - when a wrong dose of insulin is givenNear Miss Events – when a wrong dose of insulin was caught just before administrationUnsafe Conditions –Medical Device Issues – faulty insulin pumpMedical Care issues – illegible ordersNursing Care issues – poorly labeled insulin vials
12 Near misses, other accidents Why report near misses?Sentinel eventsAdverse eventsNear misses, other accidentsand occurrencesErrors that lack an adverse outcome are called near misses or precursor events. They have the same root causes as sentinel events. Most plane crashes are preceded by near misses that have been ignored. Thus, we should report near misses.
13 The anatomy of a near miss A near miss implies that a sentinel event has nearly occurred. A “near miss” is actually a poor name – a “near hit” would be better. Alternatively, a “good catch” could be used since a catastrophic event has been prevented.A near miss is a cascade of events whereby a sentinel event has been prevented due to a detection and recovery sequence. If either detection or recovery fails, the sentinel event will occur. Thus, detection and recovery play a key role in a near miss.
14 Types of near missesPlanned detection and recovery – Here, detection is a process step. Example. A lab specimen was examined for lipemia as required (planned detection) . Lipemia was found and the sample underwent an ultracentrifuge step (planned, successful recovery) before analysis.Chance detection – Detection occurred only by chance. Example – A portable BP monitor was disconnected during an MRI. The BP monitor was then incorrectly reconnected to the IV line. A family member noticed the incorrect connection (chance detection) and called a nurse who corrected the problem (unplanned, successful recovery).
15 Types of near missesUnsafe situation (Accident waiting to happen) – An error event is only recognized as such after a chance detection. Example – Two similar looking medications are next to each other. If an incorrect selection is made, the result could be fatal. Placing the similar medications next to each other can be considered to be a process error event. This error event may be a cause for selection of the incorrect medication. If the wrong medication is selected and this error is detected before administering the medication (chance detection and unplanned, successful recovery), a near miss has occurred.
16 How risks of sentinel events and near misses can be reduced Reducing risk of sentinel events means reducing the likelihood that the effect of an error event will occur. This can be accomplished by:reducing the likelihood of an error eventadding or improving a detection step for that error eventadding or improving a recovery step for that error event
17 How to Deal with a Sentinel Event / Adverse Event Persons accountableUnit heads / dept chairsImmediate Containment ActionAP, Unit heads / dept chairs + Customer ServiceUnit heads / dept chairs, AP, Team + Risk Management OfficeReporting and NotificationInvestigation and ReviewUnit heads / dept chairs, SQD + MQIOAction Plan & Monitoring
18 How to immediately contain a sentinel event 1. Continue to take CARE of the PatientAddress current health care needsObtain necessary referrals and introduce to patient / family all new members of medical care team2. PRESERVE the EvidenceSequester all involved machinery (pumps, anesthesia machines) and preserve settingsSequester all involved medication equipment (syringes, IV tubing, medication vials)Activate or acquire back-up equipment
19 How to immediately contain a sentinel event 3. DOCUMENT in the Medical RecordInclude only verifiable facts about the event, care given in response and new care plansDO NOT include subjective feelings or beliefs, events which you did not personally witness, hearsay evidence4. Plan for timely PATIENT DISCLOSUREWhy disclose? Patients have the right to know.Who will disclose? The AP is responsible for disclosure. The hospital may form a team to assist him in planning for the disclosure.When to disclose? As promptly as the patient’s condition will allow. Timely disclosure rebuilds a patient’s trust.
20 How to immediately contain a sentinel event Plan for timely PATIENT DISCLOSUREWhat to disclose?”Known Facts”Objective verifiable information, documented in Medical RecordAdequate to ensure patient / family‘s understanding of eventPatient’s likely health outcome and prognosisExpress regret and convey empathy (“We regret that this incident happened.”)Avoid speculation and blame
21 How to Deal with a Sentinel Event / Adverse Event Persons accountableUnit heads / dept chairsImmediate Containment ActionAP, Unit heads / dept chairs + Customer ServiceUnit heads / dept chairs, AP, Team + Risk Management OfficeReporting and NotificationInvestigation and ReviewUnit heads / dept chairs, SQD + MQIOAction Plan & Monitoring
22 How to report a Sentinel Event / Adverse Event REPORT the Event to MQIO by completing a Sentinel Event Report Form within 24 hours.Do Not Place in Medical Record or Discuss in Medical RecordDo Not PhotocopyAn Incident Report may also be required.OR you can simply call the Safety Hotline 8777.
23 How to Deal with a Sentinel Event / Adverse Event Persons accountableUnit heads / dept chairsImmediate Containment ActionAP, Unit heads / dept chairs + Customer ServiceUnit heads / dept chairs, AP, Team + Risk Management OfficeReporting and NotificationInvestigation and ReviewUnit heads / dept chairs, SQD + MQIOAction Plan & Monitoring
24 How is a sentinel event investigated? RMO organizes a small team of leaders to analyze the event with those involvedThe focus of the analysis is NOT to assign blame but to search for underlying causes.Most sentinel events happen not because staff members intend to make mistakes but because there are inadequate systems to make the right thing easy to do (or to make the wrong thing difficult to do).The search for the root causes of sentinel events is called Root Cause Analysis (RCA).
25 A system designed for errors Root causes here!Patient gets wrong drugPharmacists mistake one drug for anotherPharmacy stocks look alike drugsOpen formulary; Doctors can write illegibly and abbreviate ordersNurses care for many patientsNurses misread ordersPatients don’t speak upResidents do not review ordersNurses do not check
26 Types of process variation For a sentinel event to occur there must be a deviation or variation from the desired processCommon-cause variation is intrinsic to the process itself. They cannot be eliminated but they can be reduced.Special-cause variation occurs because of an unusual external circumstance that affects the process. They should be identified and eliminated.However, elimintaing a special-cause variation (e.g., firing an errant employee) will not prevent the recurrence of a sentinel event because the processes that permitted the error are still in place. This is why root causes of a sentinel event must be identified.
27 The focus of RCARCA focuses on redesigning processes to reduce common-cause variationsSpecial-cause variations in the performance of patient care are frequently the result of common-cause variations in organization systems.This relationship provides the opportunity to decrease the risk of special-cause variations in one process by redesigning the larger system of which it is a part.For example, improving communication between doctors and nurses, such as routine read-back of orders, will prevent nurses from mistranscribing drugs in SHAMAN.
28 What is an acceptable RCA? The analysis focuses primarily on systems and processes, not on individual performanceThe analysis progresses from special causes in clinical processes to common causes in organizational processesThe analysis repeatedly digs deeper by asking “Why?”; then, when answered, “Why?” again, and so onThe analysis identifies changes that could be made in systems and processes (either through redesign or development of new systems or processes) which would reduce the risk of such events occurring in the futureThe analysis is thorough and credible
29 What is a thorough RCA?A determination of the human and other factors most directly associated with the sentinel event and the process(es) and systems related to its occurrenceAn analysis of the underlying systems and processes through a series of “Why?” questions to determine where redesign might reduce riskAn inquiry into all areas appropriate to the specific type of event (see next slide)An identification of risk points and their potential contributions to this type of eventA determination of potential improvement in processes or systems that would tend to decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunities exist
30 Minimum scope of RCA depending on sentinel event
31 What is a credible RCA?Include participation by the leadership of the organization and by individuals most closely involved in the processes and systems under reviewBe internally consistent (that is, not contradict itself or leave obvious questions unanswered)Provide an explanation for all findings of “not applicable” or “no problem”Include consideration of any relevant literature
32 What is Failure Mode and Effects Analysis (FMEA)? FMEA focuses on projecting what are the steps in a process that are prone to failure and providing barriers to protect patients and staff from these failures.For example, in drug administration, the failures may include wrong drug ordering, wrong drug computation, wrong encoding, wrong drug dispensing and administration to wrong patient.Failures are then prioritized based on their negative impact and likelihood of occurrence.Failure prone steps are then either eliminated or redesigned to make failures less likely or at least more easily detectable.
33 How FMEA and RCA can eliminate near misses Planned detection and recovery – FMEA analysis seeks to add planned detection and recovery where they were absent or to improve detection and recovery, by asking how can an error event be detected and what is the recovery.Chance detection – During FMEA analysis, the addition of a detection step can be thought of as changing a chance detection to a planned detection. If an error event has occurred and been detected by chance, the addition of this detection as a planned process step would have been achieved through RCA.
34 How FMEA and RCA can eliminate near misses Unsafe situation – An unsafe situation is an unrecognized error event. By definition if the error event is unrecognized, detection and recovery are unknown. By analyzing the process steps through FMEA, events that were previously unrecognized as potential errors could now be so recognized. Planned detection and recovery steps could then be added.Chance detection implies an unsafe situation - If one considers the BP problem above, one could suggest that having a BP Luer connector that can attach to an IV line is an unsafe situation (e.g., an error). Starting with that premise there are several possible mitigations including training, warning labels, and different equipment that would prevent the incorrect connection.
35 How to Deal with a Sentinel Event / Adverse Event Persons accountableUnit heads / dept chairsImmediate Containment ActionAP, Unit heads / dept chairs + Customer ServiceUnit heads / dept chairs, AP, Team + Risk Management OfficeReporting and NotificationInvestigation and ReviewUnit heads / dept chairs, SQD + MQIOAction Plan & Monitoring
36 What is an acceptable action plan? Identifies changes that can be implemented to reduce risk or formulates a rationale for not undertaking such changesIdentifies, in situations where improvement actions are planned, who is responsible for implementation, when the action will be implemented (including any pilot testing), and how the effectiveness of the actions will be evaluated
37 Sentinel event and near miss reporting promotes a culture of patient safety The key to improving safety lies not in changing the human condition, but in changing the conditions under which humans work.Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990
38 Sentinel event and near miss reporting promotes a culture of patient safety You can do your share in installing a culture of safety that continuously seeks to minimize hazards and patient harm that may result from the processes of healthcare.We depend on you toReport sentinel events and near missesTake part in RCAs and FMEAsBe part of the action to reduce sentinel events and near misses
39 Are you a patient safety advocate? Which of the following is/are TMC sentinel event/s:Death from acute myocardial infarctionVentilator-associated pneumoniaWrong patient procedureAll of the aboveAnswer?You must make a sentinel event report whenAn error has resulted in serious harm to a patient.Two unlabelled insulin vials are found next to each other.The surgical mark and the actual site of incision do not match.All of the above.
40 Are you a patient safety advocate? 3. The first step in dealing with a sentinel event isSubmit a properly filled out report to MQIO.Take care of the patient’s health needs.Sequester all equipment and drugs.All of the aboveAnswer?4. Patient disclosure must beDone after sufficient root cause analysisDone when all the facts are inDone to enable a patient to continue to participate in her care
41 Are you a patient safety advocate? 5. Errors usually happenDue to disregard for SOPsWhen system barriers and defenses are breachedBecause of inefficiencies and bad work attitudes..All of the aboveAnswer?6. We must report near misses becauseThey are the precursors of sentinel eventsTheir root causes are the same as sentinel eventsJust because they did not harm the patient does not mean they won’t next time
42 Are you a patient safety advocate? 7. Which of the following is a reportable unsafe condition?a. OF is administered using a venoset.b. Syrups are given to kids by syringec. Pharmacy has drugs with similar brand names.d. All of the above.Answer?8. How does FMEA and RCA eliminate near misses?Steps to detect a potential error can be added.Detection of an error by chance can be converted to routine detection.Recovery from an error can be planned.All of the above
43 Are you a patient safety advocate? 8 out of 8 – you are a pillar of our safety culture!6 or 7 out of 8 – you are a budding role model in patient safety4 or 5 out of 8 – you must strive to be better than the rest; your patients will thank you2 or 3 out of 8 – improving your understanding of patient safety is key to changing your behavior!*0 or 1 out of 8 – let us try again** Please go over the slides again.Check your answers:CDB
44 This SIM Card certifies that ______(please overwrite with your name, thank you)__, MD has successfully completed the Self Instructional Module on Sentinel Events and Near Misses Reporting, Analysis and Prevention (Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin President and CEO Director, Medical Quality Improvement