Module 4: Comprehensive analysis method
PatientSafetyCanada
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Jan 15, 2013
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About This Presentation
During this module, the key features and main steps to analyze an incident using the comprehensive method will be described, discussed and applied. In addition, the tools that facilitate a comprehensive analysis will be introduced: the timeline, human factors, diagramming contributing factors and th...
Slide Content
Incident Analysis Learning Program - Module Four
Comprehensive Analysis Method
Jan. 10, 2013
Comprehensive Analysis Method
Jan. 10, 2013
Welcome
Sandi Kossey Ioana Popescu Erin Pollock Tina Cullimore
Sandi Kossey Ioana Popescu Erin Pollock Tina Cullimore
WHAT HAPPENED?
HOW AND WHY?
WHAT CAN BE
DONE?
WHAT WAS LEARNED?
M3 Learning Program
HOW AND WHY?
WHAT CAN BE
DONE?
WHAT WAS LEARNED?
M3 Learning Program
Analysis Methods
•Canadian Incident Analysis
Framework
•Systematic Systems Analysis
• Local framework
• Other (VA, NPSA)
•Canadian Incident Analysis
Framework
•Systematic Systems Analysis
• Local framework
• Other (VA, NPSA)
Learning Objectives
The knowledge elements include an understanding of the:
•Steps to take when undertaking a comprehensive analysis
•Benefits and limitations of different diagramming tools
•Various considerations when writing statements of
findings
The performance elements include the ability to:
•Describe the steps to create a timeline of the event
•Perform the main steps to analyze information to identify
contributing factors and relationships
The knowledge elements include an understanding of the:
•Steps to take when undertaking a comprehensive analysis
•Benefits and limitations of different diagramming tools
•Various considerations when writing statements of
findings
The performance elements include the ability to:
•Describe the steps to create a timeline of the event
•Perform the main steps to analyze information to identify
contributing factors and relationships
Agenda
3-parts
•Knowledge expert
•Practice leader
•Facilitated discussion
3-parts
•Knowledge expert
•Practice leader
•Facilitated discussion
7
Introducing: WebEx
11-Jan-13 7
Be prepared to use:
- Raise Hand & Checkmark
- Chat & Q&A
- Pointer & Text
Introducing: WebEx
11-Jan-13 7
Be prepared to use:
- Raise Hand & Checkmark
- Chat & Q&A
- Pointer & Text
About You M2
Presentation
Wayne Miller
Wayne Miller
Has this ever happened in one of
your facilities?
3:45 pm Call from Nurse manager – Patient has been
given the wrong medication. Patient is unconscious
and has been moved to the ICU and assessment is
ongoing.
your facilities?
3:45 pm Call from Nurse manager – Patient has been
given the wrong medication. Patient is unconscious
and has been moved to the ICU and assessment is
ongoing.
Individual Perspectives to
Leading Practices
Key Features of Incident Analysis
•Timely, Thorough
•Objective and Impartial (avoid conflicts of interest or perceived
conflicts)
•Credible
•Interdisciplinary, Including Frontline, Patient/Family, and Non-
regulated staff
Practise / Preparing
•Who, When, and How is the analysis conducted in your
organization
•Build Teams - Quality, IT, Health Records, Bio Med
•Run simulations
•
Just and trusting culture encourages, supports, and
expects the reporting of safety and learning events.
M2
Leading Practices
Key Features of Incident Analysis
•Timely, Thorough
•Objective and Impartial (avoid conflicts of interest or perceived
conflicts)
•Credible
•Interdisciplinary, Including Frontline, Patient/Family, and Non-
regulated staff
Practise / Preparing
•Who, When, and How is the analysis conducted in your
organization
•Build Teams - Quality, IT, Health Records, Bio Med
•Run simulations
•
Just and trusting culture encourages, supports, and
expects the reporting of safety and learning events.
M2
Page 39
Canadian
Incident
Analysis
Framework
Canadian
Incident
Analysis
Framework
Gather Information
•Caution…Do not jump to solutions, conclusions,
and assumptions.
•Caution…The team will not understand the
contributing factors related to the incident if they
do not understand the circumstances surrounding
the incident.
•Caution…The facilitator must have systematic
processes for identifying the gaps in information
and for accurately addressing those gaps.
•Caution…Do not jump to solutions, conclusions,
and assumptions.
•Caution…The team will not understand the
contributing factors related to the incident if they
do not understand the circumstances surrounding
the incident.
•Caution…The facilitator must have systematic
processes for identifying the gaps in information
and for accurately addressing those gaps.
WHAT HAPPENED?
•Get a Game Plan – Each Incident is different
•Gather Information
•Review the Incident (Occurrence) Report
•Review Additional information
•Create a Detailed Timeline
•Review Supporting Information
•Get a Game Plan – Each Incident is different
•Gather Information
•Review the Incident (Occurrence) Report
•Review Additional information
•Create a Detailed Timeline
•Review Supporting Information
Review the Incident Report &
Additional information
•Triggers for a comprehensive analysis
•Incident report is based on initial understanding
•Others
•Review the health record
•Conduct interviews
•Visit the location where the incident occurred
•Secure items OR look at similar items/devices to
help build that understanding
Additional information
•Triggers for a comprehensive analysis
•Incident report is based on initial understanding
•Others
•Review the health record
•Conduct interviews
•Visit the location where the incident occurred
•Secure items OR look at similar items/devices to
help build that understanding
Create a Detailed Timeline
Example
(p.104)
Example
(p.104)
Review Supporting Information
•Includes:
•Review of Policies and Procedures
•Look at previously reported similar incidents
•Environmental Scan
•Literature Search
•Policies and Practices in leading organizations
•Consultation with colleagues or experts in the field.
•Includes:
•Review of Policies and Procedures
•Look at previously reported similar incidents
•Environmental Scan
•Literature Search
•Policies and Practices in leading organizations
•Consultation with colleagues or experts in the field.
HOW AND WHY IT HAPPENED?
•Analyze information to identify contributing factors
and relationships
•Uses systems theory and human factors
•Uses diagramming
•Summarizes findings
•Analyze information to identify contributing factors
and relationships
•Uses systems theory and human factors
•Uses diagramming
•Summarizes findings
Analyze Information
•Build on understanding by asking questions to
determine contributing factors and relationships of
factors to the event.
•Appendix G, Page 89, Guiding Questions
•Allows lens to focus on system issues which may
have contributed to the event—rather than focus on
the person
•What was this influenced by?
•What else affected the circumstances?
•Build on understanding by asking questions to
determine contributing factors and relationships of
factors to the event.
•Appendix G, Page 89, Guiding Questions
•Allows lens to focus on system issues which may
have contributed to the event—rather than focus on
the person
•What was this influenced by?
•What else affected the circumstances?
Use Systems Theory and Human
Factors
Systems Theory
Focuses on an assessment of
the individual’s action within
the context of the
circumstances at the time,
NOT on the individual alone.
Human Factors
Interaction between the
human and the system
Factors
Systems Theory
Focuses on an assessment of
the individual’s action within
the context of the
circumstances at the time,
NOT on the individual alone.
Human Factors
Interaction between the
human and the system
Use Diagramming
•Identify and understand
inter-relationships between
and among contributing
factors
•Provides a map which, when
used correctly, helps the
team identify the “route”
which was taken and why it
was taken.
•Shifts the focus from the
person to the system in
which the person works.
•Identify and understand
inter-relationships between
and among contributing
factors
•Provides a map which, when
used correctly, helps the
team identify the “route”
which was taken and why it
was taken.
•Shifts the focus from the
person to the system in
which the person works.
Diagramming— Ishikawa
Diagram
Diagram
Diagramming—Tree Diagram
Constellation Diagramming—5
steps
•Step 1: Describe the incident
•Step 2: Identify potential contributing factors
•Step 3: Define inter-relationships between and
among potential contributing factors.
•Step 4: Identify the findings
•Step 5: Confirm the findings with the team
steps
•Step 1: Describe the incident
•Step 2: Identify potential contributing factors
•Step 3: Define inter-relationships between and
among potential contributing factors.
•Step 4: Identify the findings
•Step 5: Confirm the findings with the team
Guiding Questions
Appendix G (p. 89)
Example
Appendix G (p. 89)
Example
Summarize Findings
•Statements of findings
•Describe the relationships between the contributing
factors and the incident and/or outcome.
•Three categories of findings:
Factors that if corrected would likely have prevented
the incident or mitigated the harm.
Factors that if corrected, would NOT have prevented
the incident or mitigated the harm, but are
important for patient/staff safety or safe patient care
in general
Mitigating factors—factors that didn’t allow the
incident to have more serious consequences and
represent solid safeguards that should be kept in
place
•Statements of findings
•Describe the relationships between the contributing
factors and the incident and/or outcome.
•Three categories of findings:
Factors that if corrected would likely have prevented
the incident or mitigated the harm.
Factors that if corrected, would NOT have prevented
the incident or mitigated the harm, but are
important for patient/staff safety or safe patient care
in general
Mitigating factors—factors that didn’t allow the
incident to have more serious consequences and
represent solid safeguards that should be kept in
place
Statement of Findings
Example
“The use of gravity intravenous infusion
sets in the Emergency Department
increased the likelihood that an
intravenous narcotics infusion would be
infused at a higher than intended rate
when the patient changed his position on
the stretcher”
Example
“The use of gravity intravenous infusion
sets in the Emergency Department
increased the likelihood that an
intravenous narcotics infusion would be
infused at a higher than intended rate
when the patient changed his position on
the stretcher”
Confirm Findings
Team should agree on the findings before developing
recommended actions
Work through disagreements to achieve consensus
If key individuals who were involved in the event were
not part of the analysis team, ask for their feedback
on the findings.
Include a Back-Checking Step
Team should agree on the findings before developing
recommended actions
Work through disagreements to achieve consensus
If key individuals who were involved in the event were
not part of the analysis team, ask for their feedback
on the findings.
Include a Back-Checking Step
Ultimate Goal
To
WHAT CAN BE DONE TO REDUCE THE RISK OF
RECURRENCE AND MAKE CARE SAFER
To
WHAT CAN BE DONE TO REDUCE THE RISK OF
RECURRENCE AND MAKE CARE SAFER
WHAT WAS LEARNED?
Healthcare providers work very hard to provide safe
care in the best way they know how.
Let’s not ask them to do this risky work without a net
Healthcare providers work very hard to provide safe
care in the best way they know how.
Let’s not ask them to do this risky work without a net
Real- life Experience
Dr. Chris Hayes
Dr. Chris Hayes
Incident Analysis Framework:
Real-life Experience
Module 4: Comprehensive analysis method
January 10, 2013
Real-life Experience
Module 4: Comprehensive analysis method
January 10, 2013
What is critical incident
(ie. a severe harmful patient safety incident)
•Any unintended event that occurs when a
patient receives treatment in the hospital,
–that results in death, or serious disability,
injury or harm to the patient, and
–does not result primarily from the patients'
underlying medical condition or from a known
risk inherent in providing the treatment
(ie. a severe harmful patient safety incident)
•Any unintended event that occurs when a
patient receives treatment in the hospital,
–that results in death, or serious disability,
injury or harm to the patient, and
–does not result primarily from the patients'
underlying medical condition or from a known
risk inherent in providing the treatment
•Any unintended event that occurs when a
patient receives treatment in the hospital,
–that results in death, or serious disability,
injury or harm to the patient, and
–does not result primarily from the patients'
underlying medical condition or from a known
risk inherent in providing the treatment
•Not factored into the definition at St.
Michael’s
–perspective of patient outcome is considered
first….harm feels like harm!!
–assumes inherent risks are fixed with no
potential in learning or reducing…eg CLI
–data supports inherent risk of death d/t
adverse events = 1/116
What is critical incident
(ie. a severe harmful patient safety incident)
patient receives treatment in the hospital,
–that results in death, or serious disability,
injury or harm to the patient, and
–does not result primarily from the patients'
underlying medical condition or from a known
risk inherent in providing the treatment
•Not factored into the definition at St.
Michael’s
–perspective of patient outcome is considered
first….harm feels like harm!!
–assumes inherent risks are fixed with no
potential in learning or reducing…eg CLI
–data supports inherent risk of death d/t
adverse events = 1/116
What is critical incident
(ie. a severe harmful patient safety incident)
An example
•Patient admitted to the ICU following a large stroke. At
approximately midnight the patient began having generalized
seizures. She paged the resident on call. The resident came and
asked for some Ativan. As the resident was giving the Ativan he
asked the nurse to quickly get some Dilantin (phenytoin). The nurse
left the bedside to prepare the medication in an IV minibag, returned
to the bedside and began to hang the drug. Meanwhile the Ativan
had stopped the seizure and the resident returned to his call room.
•20 minutes later the patient’s blood pressure rose to 230 over 120
mmHg. The patient began complaining of chest pain and was
visibly short of breath. The nurse paged the resident to the bedside
STAT. The resident on arrival asked for some IV metoprolol. He
gave 20mg in total with little effect on the blood pressure.
•Patient admitted to the ICU following a large stroke. At
approximately midnight the patient began having generalized
seizures. She paged the resident on call. The resident came and
asked for some Ativan. As the resident was giving the Ativan he
asked the nurse to quickly get some Dilantin (phenytoin). The nurse
left the bedside to prepare the medication in an IV minibag, returned
to the bedside and began to hang the drug. Meanwhile the Ativan
had stopped the seizure and the resident returned to his call room.
•20 minutes later the patient’s blood pressure rose to 230 over 120
mmHg. The patient began complaining of chest pain and was
visibly short of breath. The nurse paged the resident to the bedside
STAT. The resident on arrival asked for some IV metoprolol. He
gave 20mg in total with little effect on the blood pressure.
An example
•Eventually the patient was stabilized but had suffered a large heart
attack and now had significant congestive heart failure.
•Later that evening the resident noticed a vial of phenylephrine at the
patient’s bedside. He showed this to the nurse who became
immediately very upset and was later sent home.
•The Charge Nurse reported the incident later that evening, the
family was informed of the incident and received an apology
•Risk Management & QI team reviewed the incident details and
decided that a comprehensive review be conducted
•Eventually the patient was stabilized but had suffered a large heart
attack and now had significant congestive heart failure.
•Later that evening the resident noticed a vial of phenylephrine at the
patient’s bedside. He showed this to the nurse who became
immediately very upset and was later sent home.
•The Charge Nurse reported the incident later that evening, the
family was informed of the incident and received an apology
•Risk Management & QI team reviewed the incident details and
decided that a comprehensive review be conducted
So it’s an adverse event
•The next phase is to analyze the event in
order to know:
–What happened
–How and why it happened
–What can be done to reduce the likelihood of
recurrence and make care safer
–What was learned
•The next phase is to analyze the event in
order to know:
–What happened
–How and why it happened
–What can be done to reduce the likelihood of
recurrence and make care safer
–What was learned
Conducting the analysis
Date / Time Information item Comment / Source
Jan 1, 12 22:45 Patient admitted with stroke Patient record
23:35 Patient develops GTC seizure Nurses notes, confirmed by
nurse interview
23:40 Resident assessed, gave Ativan and verbally
ordered Dilantin 1g over 20 min
Patient record, confirmed by
resident interview
23:55 Nurse finished preparing, hung and administered
Dilantin
Patient record, confirmed by
nurse interview
Jan 2, 12 00:20 Patient blood pressure noted at 230/120, requring
more oxygen
Patient record
00:50 Patient’s BP resolved but requiring more oxygen Patient record
~01:20 Bottle of phenylephrine discovered at bedside Interview with resident
~01:50 Bedside nurse relieved of duty and went home Interview with charge nurse
10:30 Echo done and shows Grade 3 LV Patient record
Conducting the analysis
Jan 1, 12 22:45 Patient admitted with stroke Patient record
23:35 Patient develops GTC seizure Nurses notes, confirmed by
nurse interview
23:40 Resident assessed, gave Ativan and verbally
ordered Dilantin 1g over 20 min
Patient record, confirmed by
resident interview
23:55 Nurse finished preparing, hung and administered
Dilantin
Patient record, confirmed by
nurse interview
Jan 2, 12 00:20 Patient blood pressure noted at 230/120, requring
more oxygen
Patient record
00:50 Patient’s BP resolved but requiring more oxygen Patient record
~01:20 Bottle of phenylephrine discovered at bedside Interview with resident
~01:50 Bedside nurse relieved of duty and went home Interview with charge nurse
10:30 Echo done and shows Grade 3 LV Patient record
Conducting the analysis
Conducting the analysis
Conducting the analysis
Nurse had to
leave bedside to
prepare med
Double-check policy
does not include
anticonvulsants
Sound- alike, look
alike drugs stored
together
Acute issue, middle of night
Verbal order given
Patient suffers large MI and CHF following wrong drug administration
Nurse had to
leave bedside to
prepare med
Double-check policy
does not include
anticonvulsants
Sound- alike, look
alike drugs stored
together
Acute issue, middle of night
Verbal order given
Patient suffers large MI and CHF following wrong drug administration
Hazards
Sound-alike
look-alike
drug
Losses
CHF/MI RN/MD Double- check
Medication
organization
Purchasing
Manufacturer
“Swiss Cheese” model
Sound-alike
look-alike
drug
Losses
CHF/MI RN/MD Double- check
Medication
organization
Purchasing
Manufacturer
“Swiss Cheese” model
What did we do?
What did we do?
Recommendations / Actions
•Introduced TallMan lettering
•Removed multi-drug bins and reorganized med
cabinets
•Moved phenytoin under “D” for dilantin
•Did the same for all other ICUs, then all wards
•Met with Clinical Services Committee and
Pharmacy re purchasing of sound- alike, look-
alike drugs
•Discussed the problem and the solution openly
•Introduced TallMan lettering
•Removed multi-drug bins and reorganized med
cabinets
•Moved phenytoin under “D” for dilantin
•Did the same for all other ICUs, then all wards
•Met with Clinical Services Committee and
Pharmacy re purchasing of sound- alike, look-
alike drugs
•Discussed the problem and the solution openly
Recommendations / Actions
Summary
•Incident analysis is a standard process to learn what,
why and how an patient safety incident occurred
•An interprofessional, open and just approach fosters
greater learning
•Requires gathering of material facts and interviews of
those involved
•Requires open exploration of all contributing system
factors
•Done right…leads to effective recommendations and
improvement in patient safety
•Incident analysis is a standard process to learn what,
why and how an patient safety incident occurred
•An interprofessional, open and just approach fosters
greater learning
•Requires gathering of material facts and interviews of
those involved
•Requires open exploration of all contributing system
factors
•Done right…leads to effective recommendations and
improvement in patient safety
Case Study – Virtual Group Exercise
Most participants will
“move” to breakout
rooms
Some participants will
stay in the main room
Those prompted: click
YES to both pop-up
screens to “move”
Breakout Session
“move” to breakout
rooms
Some participants will
stay in the main room
Those prompted: click
YES to both pop-up
screens to “move”
Breakout Session
Small Group Discussion
-Share your organization’s comprehensive analysis
process
(what works well and what can be improved)
-Point out the differences with the comprehensive
method presented
(4 objectives, steps, tools)
-What would you need to do tomorrow to make the
comprehensive analysis more effective
0 Experience with comprehensive analysis 10
-Share your organization’s comprehensive analysis
process
(what works well and what can be improved)
-Point out the differences with the comprehensive
method presented
(4 objectives, steps, tools)
-What would you need to do tomorrow to make the
comprehensive analysis more effective
0 Experience with comprehensive analysis 10
Large Group De- Briefing
Wrap-up
Next Steps
•End of session evaluation certificate of attendance
•Follow up survey we learn from you
Incident Analysis Learning Program
•Concise analysis – January 31, 2013
•Multi-incident analysis – February 21, 2013
•Recommendations management – March 7, 2013
•Follow-through and share what was learned – March 28,
2013
•End of session evaluation certificate of attendance
•Follow up survey we learn from you
Incident Analysis Learning Program
•Concise analysis – January 31, 2013
•Multi-incident analysis – February 21, 2013
•Recommendations management – March 7, 2013
•Follow-through and share what was learned – March 28,
2013
Resource slide
Learning Program – previous modules:
http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningP
rogram/Pages/Session-Recordings-and-Documents.aspx
HQCA’s Systematic Systems Analysis
http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Revi
ews%20FINAL%20June%202012.pdf
Incident Analysis Tools
http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnal
ysis/Pages/Tools.aspx
Learning Program – previous modules:
http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningP
rogram/Pages/Session-Recordings-and-Documents.aspx
HQCA’s Systematic Systems Analysis
http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Revi
ews%20FINAL%20June%202012.pdf
Incident Analysis Tools
http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnal
ysis/Pages/Tools.aspx
Thank You
Mulţumesc
Mulţumesc
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