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Module 6 - Multi-Incident Analysis Method

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Canadian Patient Safety Institute
Canadian Patient Safety Institute

The background, examples and steps in conducting a multi-incident analysis are described, discussed and applied during this module. Practical examples and case studies will help link the knowledge to practice.

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Incident Analysis Learning Program - Module Six Multi-Incident Analysis Method February 21, 2013
Welcome Tina Cullimore Sandi Kossey Erin Pollock Nadine Glenn Ioana Popescu
Learning Program What was learned? What can be done? How and why? What happened? Multi-incident Concise Comprehensive
Learning Objectives The rationale behind and understanding of the methodology for multi-incident analysis. Outline the steps required to undertake a multi-incident analysis Give examples of when a multi-incident analysis is recommended Agenda Knowledge + Q&A Practice + Q&A Learn together
Introducing: WebEx Be prepared to use: - Raise Hand & Checkmark - Chat & Q&A - Pointer & Text 5 22-Feb-13 5
About You 0 Knowledge of [any] MULTI-INCIDENT analysis 10
Presentation Polly Stevens, Faculty
Method Comparison
Types of Multi-Patient Incident Analyses Type 1 – Analysis of Many Previous Single-Patient Incidents/Reviews A. Homogeneous incidents/reviews over a period of time B. Heterogeneous incidents/reviews over a period of time  Varying degrees of harm (including near miss)  AKA: cluster, aggregate, meta-analysis Type 2 – Analysis of a Group of Patients Who Have / May Have Been Impacted by an Incident  Varying degrees of harm (unknown to severe)  AKA: look-backs
Why? Type 1 – Analysis of Many Previous Single-Patient Incidents/Reviews  To identify themes, relative frequencies of incidents and/or contributing factors; assess trends over time; assess implementation of recommendations; obtain “forest” perspective Type 2 – Analysis of a Group of Patients Who Have / May Have Been Impacted by an Incident  To identify if harm occurred (threshold determination key); and if so, who was impacted  Then, as per single (comprehensive) analysis, to identify how and why it occurred, what can be done to reduce risk  Usually feeds into multi-patient notification
Type 1-A: Example
Type 1-A: Examples http://www.ismp-canada.org/ISMPCSafetyBulletins.htm
Type 1-B: Example Total of 30 Reviews Medication Related (50%) Resuscitation (13%) Patient Identification (13%) Reached Patient (79%) Caused Harm (35%) Cronin, Healthcare Quarterly Vol. 9, 2006
Type 1-B: Example
Type 2: Usual Suspects 1. Diagnostics (especially pathology) 2. Infection Control 3. Privacy Breach
Type 2: Examples • Toronto (1994) • Toronto (2011) o Blood/look-back o Risk of nosocomial process infection • Toronto (2003) • BC (2011) o Equipment Cleaning o Radiology • Newfoundland (2005) o Pathology • Alberta (2012) o Pathology, Radiology • Southern Ontario (2010) o Pathology • Everywhere (2010, 2011, • Toronto (2011) 2012, 2013) o Actual Nosocomial o Loss of personal health infection information
Process Overview Page 51 Canadian Incident Analysis Framework
Prepare (Type 1) 1. Determine the theme and inclusion criteria 2. Gather data 3. Convene an interdisciplinary team 4. Review literature and obtain expert opinions to lend perspective to the analysis 5. Develop the analysis plan and prepare the materials
Prepare (Type 2) 1. Convene an interdisciplinary team 2. Obtain expert opinions • clinical, epidemiological, risk management 3. Establish look back plan and gather data • carefully consider expected false negative and positive rates, particularly when using newer, more sensitive test methods 4. Assess results 5. Plan disclosure (if required) • clinical, epidemiological, ethical, legal/insurer(s), professionals
Disclose (Type 2) Pg. 30-31
What (Type 1) • Review incident reports and/or analyses and supporting information • Review additional information: policies, procedures, literature, environmental scan, previously reported incidents, previous analyses, consultations with colleagues or experts, etc. • Compare and contrast the incident reports and/or analyses that comprise the themed analysis (can use process mapping) • Complete quantitative analysis (descriptive statistics)
How and Why (Type 1) • Complete a qualitative analysis: • Compare and contrast contributing factors and/or recommended actions to look for common trends or themes • Summarize findings • Include any trends, patterns of contributing factors, and any other findings
What Can Be Done (Type 1) • Develop recommended actions • Suggest an order of priority • Forward to applicable decision maker(s) for final decisions and actions • Manage recommended actions
Then... Follow-through • Implement • Monitor • Assess Close the Loop • Share what was learned o Internally o Externally (Publish?)
Questions?
Real-life Experience Kate Wilkinson
Multi-incident Analyses An Analysis of Common Causes Identified in Near Miss Reporting © Bridgepoint Active Healthcare 2013
Patient Safety Incident Patient Safety Incident Reached the patient Did not reach the patient Harmful Incident No Harm Incident Near Miss At Bridgepoint the term Good Catch is used to refer collectively to either a near miss or a reportable circumstance © Bridgepoint Active Healthcare 2013 Slide 28
Why Near Misses • Valuable source of knowledge on how safe is your system • Provides data for development of strategies for patient safety improvement • Determine system and process issues that may contribute to errors reaching the patient • Enhance reporting by providing meaningful feedback to staff © Bridgepoint Active Healthcare 2013 Slide 29
Driving Improvement • Review ‘clusters’ of no harm events or near misses • Looking for common themes • Understand system vulnerabilities © Bridgepoint Active Healthcare 2013 Slide 30
0% % time reviewing near miss incidents 100% © Bridgepoint Active Healthcare 2013 Slide 31
Prepare for Analysis • Determine theme or focus of review • Determine what type of data you have or may need to collect • Develop a framework to record information © Bridgepoint Active Healthcare 2013 Slide 32
Understand What Happened Incident report database – Report filters • Good Catch • Medication / Fluid • Falls • Compare and contrast incident report data © Bridgepoint Active Healthcare 2013 Slide 33
Common Cause Analysis • Developed Common Cause tracking tool • Analyzed reported Good Catches for Medication/Fluid events and Fall events between June 1, 2011 and June 2012 • Identified occurrence of both system, individual and patient factors © Bridgepoint Active Healthcare 2013 Slide 34
Medication / Fluids • Total of 18 Good Catches that were either type A or B classification*:  A = Potential error in process e.g.: Pharmacist noted wrong medication dispensed before leaving pharmacy; or a sound-a-like/look-a-like medication stored side by side  B = Error detected before administration of 1st dose e.g.: error noted by nurse when transcribing order; or a wrong medication caught before 1st dose given to patient * NCC MERP Index for Categorizing Medication Error © Bridgepoint Active Healthcare 2013 Slide 35
System & Individual Factors Individual System Inattention Missing/Incorrect information Distraction Work Flow Lapse in judgment Poor hand off/lack of information Misinterpretation Checking/validating Failure to validate Policy/Protocol Short cut taken Technology Knowledge/Skills Human Factors Environment/noise Culture/team work Work load/span of control. © Bridgepoint Active Healthcare 2013 Slide 36
What Did We Learn… • Failure to validate was the highest cause of the potential error • Missing or incorrect information noted primarily occurs as part of admission process – Medication reconciliation by pharmacist caught errors before reached patient • Sound-a-like errors occurred on a small number of occasions © Bridgepoint Active Healthcare 2013 Slide 37
Near Miss Falls • 116 reported Good Catches for risk of Falls • Number one contributing factors relate to Behavioral /Cognitive issues resulting in: • Not requesting assistance with transfers or for other comfort measures • Not using mobility devices appropriately • Failing to comply with the documented plan of care was noted on two occasions • 33% files had documented changes to the plan of care as a result of the report © Bridgepoint Active Healthcare 2013 Slide 38
Contributing Factors A simple tally sheet is used to collect all contributing factors documented System Individual Patient Clutter/Trip Hazards in room or Risk not known as assessment not Did not request assistance with hallways yet completed or re-evaluated transfers or for other comfort measures Floor Surfaces Call Bells / equipment not left in Does not have well fitting, non slip Slippery / uneven reach of patient footwear Inappropriate Lighting Established plan of care not Patient does not follow / followed by staff (e.g. bed alarm, understand instructions given to floor mat) prevent falls Equipment failure Bed not left in optimal position for Family does not follow / safe transfers understand instructions given to prevent falls Equipment not available Locks not engaged bed / W/C Cognitive / behavioural factors e.g. not recognizing limitations, confusion Staffing / failure to monitor Does not use mobility devices patient based on risk level appropriately Environment (bathroom not Language / Communication factors barrier free / placement of W/C) © Bridgepoint Active Healthcare 2013 Slide 39
Close the Loop • Follow up with managers where information lead the team to believe the information related to an actual incident and did not meet the definition of a Good Catch © Bridgepoint Active Healthcare 2013 Slide 40
What Can Be Done… • Presentation to PCM group – Staff meetings – Safety Huddles • Management follow-up on file improved from 61% in Q1 to 84% in Q2 • Importance of Medication reconciliation and checking information on transitions in care © Bridgepoint Active Healthcare 2013 Slide 41
Share What Was Learned • Annual Good Catch Awards 2009 - 2012 1. Pharmacist – ‘Most Serious’ – ‘Life Saver’ • Hydromorphone / Morphine pump 2. PCM - Best Management Follow-Up 3. Highest Reporting Unit or Department. © Bridgepoint Active Healthcare 2013 Slide 42
Share What Was Learned • Staff Newsletters – The Point – Safe Med Times © Bridgepoint Active Healthcare 2013 Slide 43
Share What Was Learned © Bridgepoint Active Healthcare 2013 Slide 44
Next Steps • Reporting frequency: quarterly • Expand interprofessional team involvement • Disseminate information more broadly • Include no harm or minor harm incidents © Bridgepoint Active Healthcare 2013 Slide 45
Questions?
Learn from Each Other
Options Q&A with the 2 presenters • Main room Learn from each other • Whiteboard 1: Meta-analysis o Analysis of many previous single-patient incidents • Whiteboard 2: Multi-patient o Analysis of a group of patients impacted by an incident
Recap and Next Steps End of session evaluation - tomorrow Follow up survey – 6 months • Follow-through and share what was learned March 28, 2013 • Recommendations management March 7, 2013
Resources Learning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/Inci dentAnalysisLearningProgram/Pages/Session- Recordings-and-Documents.aspx Incident Analysis Tools http://www.patientsafetyinstitute.ca/English/toolsReso urces/IncidentAnalysis/Pages/Tools.aspx
Mulţumesc Thank You

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Module 6 - Multi-Incident Analysis Method

  • 1. Incident Analysis Learning Program - Module Six Multi-Incident Analysis Method February 21, 2013
  • 2. Welcome Tina Cullimore Sandi Kossey Erin Pollock Nadine Glenn Ioana Popescu
  • 3. Learning Program What was learned? What can be done? How and why? What happened? Multi-incident Concise Comprehensive
  • 4. Learning Objectives The rationale behind and understanding of the methodology for multi-incident analysis. Outline the steps required to undertake a multi-incident analysis Give examples of when a multi-incident analysis is recommended Agenda Knowledge + Q&A Practice + Q&A Learn together
  • 5. Introducing: WebEx Be prepared to use: - Raise Hand & Checkmark - Chat & Q&A - Pointer & Text 5 22-Feb-13 5
  • 6. About You 0 Knowledge of [any] MULTI-INCIDENT analysis 10
  • 9. Types of Multi-Patient Incident Analyses Type 1 – Analysis of Many Previous Single-Patient Incidents/Reviews A. Homogeneous incidents/reviews over a period of time B. Heterogeneous incidents/reviews over a period of time  Varying degrees of harm (including near miss)  AKA: cluster, aggregate, meta-analysis Type 2 – Analysis of a Group of Patients Who Have / May Have Been Impacted by an Incident  Varying degrees of harm (unknown to severe)  AKA: look-backs
  • 10. Why? Type 1 – Analysis of Many Previous Single-Patient Incidents/Reviews  To identify themes, relative frequencies of incidents and/or contributing factors; assess trends over time; assess implementation of recommendations; obtain “forest” perspective Type 2 – Analysis of a Group of Patients Who Have / May Have Been Impacted by an Incident  To identify if harm occurred (threshold determination key); and if so, who was impacted  Then, as per single (comprehensive) analysis, to identify how and why it occurred, what can be done to reduce risk  Usually feeds into multi-patient notification
  • 13. Type 1-B: Example Total of 30 Reviews Medication Related (50%) Resuscitation (13%) Patient Identification (13%) Reached Patient (79%) Caused Harm (35%) Cronin, Healthcare Quarterly Vol. 9, 2006
  • 15. Type 2: Usual Suspects 1. Diagnostics (especially pathology) 2. Infection Control 3. Privacy Breach
  • 16. Type 2: Examples • Toronto (1994) • Toronto (2011) o Blood/look-back o Risk of nosocomial process infection • Toronto (2003) • BC (2011) o Equipment Cleaning o Radiology • Newfoundland (2005) o Pathology • Alberta (2012) o Pathology, Radiology • Southern Ontario (2010) o Pathology • Everywhere (2010, 2011, • Toronto (2011) 2012, 2013) o Actual Nosocomial o Loss of personal health infection information
  • 18. Prepare (Type 1) 1. Determine the theme and inclusion criteria 2. Gather data 3. Convene an interdisciplinary team 4. Review literature and obtain expert opinions to lend perspective to the analysis 5. Develop the analysis plan and prepare the materials
  • 19. Prepare (Type 2) 1. Convene an interdisciplinary team 2. Obtain expert opinions • clinical, epidemiological, risk management 3. Establish look back plan and gather data • carefully consider expected false negative and positive rates, particularly when using newer, more sensitive test methods 4. Assess results 5. Plan disclosure (if required) • clinical, epidemiological, ethical, legal/insurer(s), professionals
  • 21. What (Type 1) • Review incident reports and/or analyses and supporting information • Review additional information: policies, procedures, literature, environmental scan, previously reported incidents, previous analyses, consultations with colleagues or experts, etc. • Compare and contrast the incident reports and/or analyses that comprise the themed analysis (can use process mapping) • Complete quantitative analysis (descriptive statistics)
  • 22. How and Why (Type 1) • Complete a qualitative analysis: • Compare and contrast contributing factors and/or recommended actions to look for common trends or themes • Summarize findings • Include any trends, patterns of contributing factors, and any other findings
  • 23. What Can Be Done (Type 1) • Develop recommended actions • Suggest an order of priority • Forward to applicable decision maker(s) for final decisions and actions • Manage recommended actions
  • 24. Then... Follow-through • Implement • Monitor • Assess Close the Loop • Share what was learned o Internally o Externally (Publish?)
  • 27. Multi-incident Analyses An Analysis of Common Causes Identified in Near Miss Reporting © Bridgepoint Active Healthcare 2013
  • 28. Patient Safety Incident Patient Safety Incident Reached the patient Did not reach the patient Harmful Incident No Harm Incident Near Miss At Bridgepoint the term Good Catch is used to refer collectively to either a near miss or a reportable circumstance © Bridgepoint Active Healthcare 2013 Slide 28
  • 29. Why Near Misses • Valuable source of knowledge on how safe is your system • Provides data for development of strategies for patient safety improvement • Determine system and process issues that may contribute to errors reaching the patient • Enhance reporting by providing meaningful feedback to staff © Bridgepoint Active Healthcare 2013 Slide 29
  • 30. Driving Improvement • Review ‘clusters’ of no harm events or near misses • Looking for common themes • Understand system vulnerabilities © Bridgepoint Active Healthcare 2013 Slide 30
  • 31. 0% % time reviewing near miss incidents 100% © Bridgepoint Active Healthcare 2013 Slide 31
  • 32. Prepare for Analysis • Determine theme or focus of review • Determine what type of data you have or may need to collect • Develop a framework to record information © Bridgepoint Active Healthcare 2013 Slide 32
  • 33. Understand What Happened Incident report database – Report filters • Good Catch • Medication / Fluid • Falls • Compare and contrast incident report data © Bridgepoint Active Healthcare 2013 Slide 33
  • 34. Common Cause Analysis • Developed Common Cause tracking tool • Analyzed reported Good Catches for Medication/Fluid events and Fall events between June 1, 2011 and June 2012 • Identified occurrence of both system, individual and patient factors © Bridgepoint Active Healthcare 2013 Slide 34
  • 35. Medication / Fluids • Total of 18 Good Catches that were either type A or B classification*:  A = Potential error in process e.g.: Pharmacist noted wrong medication dispensed before leaving pharmacy; or a sound-a-like/look-a-like medication stored side by side  B = Error detected before administration of 1st dose e.g.: error noted by nurse when transcribing order; or a wrong medication caught before 1st dose given to patient * NCC MERP Index for Categorizing Medication Error © Bridgepoint Active Healthcare 2013 Slide 35
  • 36. System & Individual Factors Individual System Inattention Missing/Incorrect information Distraction Work Flow Lapse in judgment Poor hand off/lack of information Misinterpretation Checking/validating Failure to validate Policy/Protocol Short cut taken Technology Knowledge/Skills Human Factors Environment/noise Culture/team work Work load/span of control. © Bridgepoint Active Healthcare 2013 Slide 36
  • 37. What Did We Learn… • Failure to validate was the highest cause of the potential error • Missing or incorrect information noted primarily occurs as part of admission process – Medication reconciliation by pharmacist caught errors before reached patient • Sound-a-like errors occurred on a small number of occasions © Bridgepoint Active Healthcare 2013 Slide 37
  • 38. Near Miss Falls • 116 reported Good Catches for risk of Falls • Number one contributing factors relate to Behavioral /Cognitive issues resulting in: • Not requesting assistance with transfers or for other comfort measures • Not using mobility devices appropriately • Failing to comply with the documented plan of care was noted on two occasions • 33% files had documented changes to the plan of care as a result of the report © Bridgepoint Active Healthcare 2013 Slide 38
  • 39. Contributing Factors A simple tally sheet is used to collect all contributing factors documented System Individual Patient Clutter/Trip Hazards in room or Risk not known as assessment not Did not request assistance with hallways yet completed or re-evaluated transfers or for other comfort measures Floor Surfaces Call Bells / equipment not left in Does not have well fitting, non slip Slippery / uneven reach of patient footwear Inappropriate Lighting Established plan of care not Patient does not follow / followed by staff (e.g. bed alarm, understand instructions given to floor mat) prevent falls Equipment failure Bed not left in optimal position for Family does not follow / safe transfers understand instructions given to prevent falls Equipment not available Locks not engaged bed / W/C Cognitive / behavioural factors e.g. not recognizing limitations, confusion Staffing / failure to monitor Does not use mobility devices patient based on risk level appropriately Environment (bathroom not Language / Communication factors barrier free / placement of W/C) © Bridgepoint Active Healthcare 2013 Slide 39
  • 40. Close the Loop • Follow up with managers where information lead the team to believe the information related to an actual incident and did not meet the definition of a Good Catch © Bridgepoint Active Healthcare 2013 Slide 40
  • 41. What Can Be Done… • Presentation to PCM group – Staff meetings – Safety Huddles • Management follow-up on file improved from 61% in Q1 to 84% in Q2 • Importance of Medication reconciliation and checking information on transitions in care © Bridgepoint Active Healthcare 2013 Slide 41
  • 42. Share What Was Learned • Annual Good Catch Awards 2009 - 2012 1. Pharmacist – ‘Most Serious’ – ‘Life Saver’ • Hydromorphone / Morphine pump 2. PCM - Best Management Follow-Up 3. Highest Reporting Unit or Department. © Bridgepoint Active Healthcare 2013 Slide 42
  • 43. Share What Was Learned • Staff Newsletters – The Point – Safe Med Times © Bridgepoint Active Healthcare 2013 Slide 43
  • 44. Share What Was Learned © Bridgepoint Active Healthcare 2013 Slide 44
  • 45. Next Steps • Reporting frequency: quarterly • Expand interprofessional team involvement • Disseminate information more broadly • Include no harm or minor harm incidents © Bridgepoint Active Healthcare 2013 Slide 45
  • 48. Options Q&A with the 2 presenters • Main room Learn from each other • Whiteboard 1: Meta-analysis o Analysis of many previous single-patient incidents • Whiteboard 2: Multi-patient o Analysis of a group of patients impacted by an incident
  • 49. Recap and Next Steps End of session evaluation - tomorrow Follow up survey – 6 months • Follow-through and share what was learned March 28, 2013 • Recommendations management March 7, 2013
  • 50. Resources Learning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/Inci dentAnalysisLearningProgram/Pages/Session- Recordings-and-Documents.aspx Incident Analysis Tools http://www.patientsafetyinstitute.ca/English/toolsReso urces/IncidentAnalysis/Pages/Tools.aspx