Transcript Document

Sentinel events and near miss
reporting, analysis and
prevention
The Good Hospital Practice
Training Series 2009
The Medical City
• 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.
There is no denying it:
Health care kills patients!
Why should we make our
hospital practice safer?
Because
• our reputation,
• our earnings, and
• our 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..
The JCI Sentinel Events Policy
Goals
1. To improve patient care, treatment and
services and prevent sentinel events
2. To focus organizational attention to a sentinel
event’s root causes and change systems and
processes to prevent its recurrence
3. To increase general knowledge of sentinel
events, their causes and prevention through
data collection
4. To maintain public confidence in accreditation
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
response
• Sentinel 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
The Medical City List of Sentinel
Events
1. Death / paralysis following surgery
2. Death / paralysis of mother/infant
undergoing delivery
3. Retained surgical instruments / materials
4. Surgery on wrong body part / wrong
patient
5. Patient fall resulting in death / paralysis
6. Serious adverse drug reactions involving
DrugWatch list drugs
7. Major blood transfusion reaction
DRUGWATCH LIST
Be careful in using these
drugs!
1.
2.
3.
4.
5.
6.
7.
Insulin
Potassium chloride
Magnesium sulfate
Calcium gluconate
Sodium bicabonate
Lidocaine
Dopamine
8. Dobutamine
9. Heparin
10. Warfarin
(Coumadin)
The Medical City list of
adverse events
1. Infection control indicators
6. Deaths from the following
conditions
1.1 hospital care related infections
(ventilator associated pneumonia,
6.1 Acute myocardial infarction
Foley catheter associated UTI, blood 6.2 Congestive heart failure
stream infections from central venous 6.3 Gastrointestinal hemorrhage
lines, surgical site infections)
6.4 Hip fracture
1.2 needlestick injuries
6.5 Pneumonia
2. Heel hematoma after blood
6.6 Stroke
extraction in neonates
7. Surgical incidents
3. Self-extubation in intubated
7.1 Postoperative hemorrhage or
patients
hematoma
4. Unanticipated death,
cardiorespiratory arrest or loss of 7.2 Postoperative infection
(localized and systemic)
major function in any admitted
patient
8. Aspiration incidents in patients
on tube feeding
5. Unplanned re-admission into the
hospital, ICU, NICU or OR
When do you report
• Actual Event - when a sentinel event or adverse
event actually happens
• Near 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 outcome
• Unsafe Conditions – that might predispose to the
sentinel event, including
– Medical Device Issues
– Medical Care issues
– Nursing Care issues
When do you report
For example, for medication incident
• Actual Event - when a wrong dose of insulin is
given
• Near Miss Events – when a wrong dose of
insulin was caught just before administration
• Unsafe Conditions –
– Medical Device Issues – faulty insulin pump
– Medical Care issues – illegible orders
– Nursing Care issues – poorly labeled insulin vials
Why report near misses?
Sentinel events
Adverse events
Near misses, other accidents
and occurrences
Errors 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.
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.
http://www.krouwerconsulting.com/Essays/NearMiss.htm
Types of near misses
Planned 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).
Types of near misses
Unsafe 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.
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 event
• adding or improving a detection step for that
error event
• adding or improving a recovery step for that
error event
How to Deal with a Sentinel
Event / Adverse Event
SENTINEL
EVENT
Persons
accountable
Unit heads /
dept chairs
Immediate
Containment
Action
AP, Unit heads
/ dept chairs
+ Customer
Service
Reporting and
Notification
Unit heads / dept
chairs, AP, Team +
Risk Management
Office
Investigation
and Review
Unit heads /
dept chairs,
SQD + MQIO
Action Plan
& Monitoring
How to immediately contain a
sentinel event
1. Continue to take CARE of the Patient
• Address current health care needs
• Obtain necessary referrals and introduce to
patient / family all new members of medical care
team
2. PRESERVE the Evidence
• Sequester all involved machinery (pumps,
anesthesia machines) and preserve settings
• Sequester all involved medication equipment
(syringes, IV tubing, medication vials)
• Activate or acquire back-up equipment
How to immediately contain a sentinel
event
3. DOCUMENT in the Medical Record
•
Include only verifiable facts about the event, care
given in response and new care plans
•
DO NOT include subjective feelings or beliefs, events
which you did not personally witness, hearsay
evidence
4. Plan for timely PATIENT DISCLOSURE
•
Why 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.
How to immediately contain a sentinel
event
Plan for timely PATIENT DISCLOSURE
What to disclose?
”Known Facts”
•
Objective verifiable information, documented in
Medical Record
•
Adequate to ensure patient / family‘s understanding
of event
•
Patient’s likely health outcome and prognosis
•
Express regret and convey empathy (“We regret
that this incident happened.”)
•
Avoid speculation and blame
How to Deal with a Sentinel
Event / Adverse Event
SENTINEL
EVENT
Persons
accountable
Unit heads /
dept chairs
Immediate
Containment
Action
AP, Unit heads
/ dept chairs
+ Customer
Service
Reporting and
Notification
Unit heads / dept
chairs, AP, Team +
Risk Management
Office
Investigation
and Review
Unit heads /
dept chairs,
SQD + MQIO
Action Plan
& Monitoring
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 Record
 Do Not Photocopy
 An Incident Report may also be required.
OR you can simply call the Safety Hotline
8777.
How to Deal with a Sentinel
Event / Adverse Event
SENTINEL
EVENT
Persons
accountable
Unit heads /
dept chairs
Immediate
Containment
Action
AP, Unit heads
/ dept chairs
+ Customer
Service
Reporting and
Notification
Unit heads / dept
chairs, AP, Team +
Risk Management
Office
Investigation
and Review
Unit heads /
dept chairs,
SQD + MQIO
Action Plan
& Monitoring
How is a sentinel event
investigated?
• RMO organizes a small team of leaders to
analyze the event with those involved
• The 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).
A system designed for errors
Root causes
here!
Open
formulary;
Doctors can
write
illegibly and
abbreviate
orders
Pharmacy
stocks look
alike drugs
Pharmacists
mistake one
drug for
another
Nurses
care for
many
patients
Nurses
misread
orders
Patient
gets
wrong
drug
Patients don’t
speak up
Residents do not
review orders
Nurses do not check
Types of process variation
• For a sentinel event to occur there must be a deviation
or variation from the desired process
• Common-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.
The focus of RCA
• RCA focuses on redesigning processes to reduce
common-cause variations
• Special-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.
What is an acceptable RCA?
1. The analysis focuses primarily on systems and
processes, not on individual performance
2. The analysis progresses from special causes in
clinical processes to common causes in
organizational processes
3. The analysis repeatedly digs deeper by asking
“Why?”; then, when answered, “Why?” again, and
so on
4. The 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 future
5. The analysis is thorough and credible
What is a thorough RCA?
1. A determination of the human and other factors most
directly associated with the sentinel event and the
process(es) and systems related to its occurrence
2. An analysis of the underlying systems and processes
through a series of “Why?” questions to determine
where redesign might reduce risk
3. An inquiry into all areas appropriate to the specific type
of event (see next slide)
4. An identification of risk points and their potential
contributions to this type of event
5. A 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
Minimum scope of RCA depending
on sentinel event
What is a credible RCA?
1. Include participation by the leadership of the
organization and by individuals most closely
involved in the processes and systems under
review
2. Be internally consistent (that is, not contradict
itself or leave obvious questions unanswered)
3. Provide an explanation for all findings of “not
applicable” or “no problem”
4. Include consideration of any relevant literature
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.
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.
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.
How to Deal with a Sentinel
Event / Adverse Event
SENTINEL
EVENT
Persons
accountable
Unit heads /
dept chairs
Immediate
Containment
Action
AP, Unit heads
/ dept chairs
+ Customer
Service
Reporting and
Notification
Unit heads / dept
chairs, AP, Team +
Risk Management
Office
Investigation
and Review
Unit heads /
dept chairs,
SQD + MQIO
Action Plan
& Monitoring
What is an acceptable action
plan?
1. Identifies changes that can be implemented to
reduce risk or formulates a rationale for not
undertaking such changes
2. Identifies, 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
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
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 to
• Report sentinel events and near misses
• Take part in RCAs and FMEAs
• Be part of the action to reduce sentinel events
and near misses
Are you a patient safety advocate?
1.
Which of the following is/are TMC sentinel event/s:
a. Death from acute myocardial infarction
b. Ventilator-associated pneumonia
c. Wrong patient procedure
d. All of the above
Answer?
2. You must make a sentinel event report when
a. An error has resulted in serious harm to a patient.
b. Two unlabelled insulin vials are found next to each
other.
c. The surgical mark and the actual site of incision do
not match.
d. All of the above.
Answer?
Are you a patient safety advocate?
3. The first step in dealing with a sentinel event is
a. Submit a properly filled out report to MQIO.
b. Take care of the patient’s health needs.
c. Sequester all equipment and drugs.
d. All of the above
Answer?
4. Patient disclosure must be
a. Done after sufficient root cause analysis
b. Done when all the facts are in
c. Done to enable a patient to continue to
participate in her care
d. All of the above
Answer?
Are you a patient safety advocate?
5. Errors usually happen
a. Due to disregard for SOPs
b. When system barriers and defenses are breached
c. Because of inefficiencies and bad work attitudes..
d. All of the above
Answer?
6. We must report near misses because
a. They are the precursors of sentinel events
b. Their root causes are the same as sentinel events
c. Just because they did not harm the patient does
not mean they won’t next time
d. All of the above
Answer?
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 syringe
c. Pharmacy has drugs with similar brand names.
d. All of the above.
Answer?
8. How does FMEA and RCA eliminate near misses?
a. Steps to detect a potential error can be added.
b. Detection of an error by chance can be
converted to routine detection.
c. Recovery from an error can be planned.
d. All of the above
Answer?
Are you a patient safety advocate?
8 out of 8 – you are a pillar of
Check your answers:
our safety culture!
6 or 7 out of 8 – you are a
1. C
budding role model in
2. D
patient safety
4 or 5 out of 8 – you must strive
3. B
to be better than the rest;
your patients will thank you
4. C
2 or 3 out of 8 – improving your
5. B
understanding of patient
safety is key to changing
6. D
your behavior!*
7. D
0 or 1 out of 8 – let us try
again*
8. D
* Please go over the slides
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
President and CEO
(Sgd) Dr Jose Acuin
Director, Medical Quality Improvement