Risk Management Plan-Response to an adverse event

Running head: RISK MANAGEMENT PLAN 1

Risk Management Plan

By:

Daniel Akins

RISK MANAGEMENT PLAN 2

Risk Management Plan

Risk management plans are necessary in healthcare organizations to minimize errors and

maximize safety. In a recent case, a hospital had an adverse event in which patients received

incorrect care. The adverse event could have been prevented by a risk management program that

required steps to ensure patients received the correct treatment and medication. This paper

contains a summary of the event, a root cause analysis, a risk management plan with

recommendations, and defined responsibilities of each staff member and provider.

Case Summary

In the case presented, two patients were affected by an adverse event. One patient

presented herself to the emergency room (ER) with serve abdominal pain and had been vomiting

for two days. The patient’s last name is Jonesky and she only spoke Russian. Jonesky is

accompanied by her husband, who spoke limited English. Jonesky is triaged and then asked to

wait for further care and instruction. After several hours and increasing pain, the patient’s

husband approaches the ER staff and after a frustrating conversation the patient was moved to a

room to be seen. Jonesky is eventually diagnosed with appendicitis and needs immediate

surgery. The language barrier between the patient and staff becomes more evident as Jonesky

was being prepped for surgery. The nurse does not understand the patient or the husband,

inadvertently translates Jonesky to Jones in the patient’s notes. During this time, another female

patient with the last name Jones was admitted into the same emergency room. Jones was being

treated for a broken ankle that required surgical repair and was prepped for surgery.

At this point in the shift, the staff had worked over eight hours and were very tired. Prior

to the surgeries of the two patients, the surgeons do not do a proper a time out to review the

cases. Both patients were brought into surgery at the same time. As the surgeons began the


operations, the Jonesky surgeon made an incision on her ankle while the surgeon for Jones made

an incision in the abdomen. Each surgeon soon realized that they made the wrong incisions.

Root Cause Analysis

Kohn, Corrigan, and Donaldson (2000) write that healthcare reports show most medical

mistakes are preventable. Through risk management and quality improvement, healthcare

professionals can improve patient safety. With cases in which errors do happen, there are

methods to find the cause and make adjustments to improve risk plans. To evaluate this case

study, a root cause analysis (RCA) will be used to explain what happened and identify how to

prevent future adverse events.

Explanation

RCA is a tool that is used by many organizations in the healthcare industry. RCA is a

linear process used to study an adverse event, identify causes of the event, and make

recommendations to prevent future adverse events (Nicolini, Waring, & Mengis, 2011). The

RCA provides healthcare organizations a way to improve patient safety and the organization’s

risk management plan. Such improvements allow for the organization to become more patient

oriented and develop a positive reputation.

Nicolini, Waring, and Mengis (2011) write that RCA employs many mapping processes

that organizations can choose from such as a fish diagram, fault trees, and cause and effect

charts. RCA is popular in the healthcare industry because it allows organizations choices in

evaluating an adverse event. No matter the technique used, a hospital will need to employ an

internal team to investigate the adverse event (Nicolini, Waring, & Mengis, 2011). A team

gathers facts, provide analysis, and make recommendations.

Connections


The Jonesky and Jones surgery mix up has been discussed but more information is

needed on roles of departments, staff, and location. Nicolini, Waring, and Mengis (2011)

suggest that in RCA investigators identify departments, locations, and staff involved in the

adverse event. By identifying all contributions to the adverse event the investigating team can

suggest improvements for patient safety and the risk management plan.

Upon arrival to the hospital, both patients went to the hospital’s emergency department

and were triaged. Boston Children’s Hospital (2012) describes triage as the process of taking the

patients vitals and determining the reason for the patient’s visit. This process is important

because it allows the hospital to determine the type of care the patient needs and also the priority

in which the patient will be seen. In the case study example both patients were moved to an

exam room and determined to require surgery. Each patient was then transported into the

operating room (OR) for surgery based on their condition.

Timeline

Nicolini, Waring, and Mengis (2011) report that having a timeline showing the

chronological order of events is beneficial for the RCA investigating team because it allows the

team to identify errors and to develop questions. A timeline organizing the adverse event should

follow the patients involved from when they first arrived at the hospital. When putting together

a timeline it is beneficial to be as detailed as possible. A timeline of the case study is presented

below.

Jonesky and her husband arrived in the ER, the husband reported to the staff that his wife

had severe abdominal and has been vomiting. The patient is triaged and told to wait in the

reception area for further care. At this point it should have been noted that Jonesky speaks only

Russian and her husband speaks limited English.


Next, Jonesky’s husband inquired about their long wait. This precipitated her being

moved out of triage and into an exam room. It is then determined that Jonesky has appendicitis

and is moved to be prepped for surgery. In the surgery prepping area, the nurse interviews the

patient and does not understand Russian and interprets Jonesky as Jones.

During the time Jonesky is being prepped for surgery a patient named Samantha Jones

comes to the ER and is determined to need surgery for a broken ankle. Samantha Jones is

prepped for surgery and enters the operating room. An important note is that T both patients

entered the OR at the same time and the surgeons did do a short time out prior to surgery.

However, the RCA team would find that the time out was perfunctory.

Next the surgeons and teams head into the ORs for surgery. During the surgery of

Jonesky, an incision is made on her ankle and the surgeon discovers that there is nothing wrong

with Jonesky’s ankle. At the same time a surgeon makes an incision in Samantha Jones’s

abdomen and notices that the patient does not have appendicitis.

Investigation Team and Method

Hambleton (2005) writes that RCA can be done by one person but suggests that the

investigation be done with a team. Including several members of the organization on the RCA

team allows for information to be gathered and analyzed at a quicker rate. To add to the

diversity of the investigation, Nicolini, Waring, and Mengis (2011) suggest that the investigation

team consist of members from different groups in the hospital. Such diversity will add different

viewpoints in collecting information and determining the causes of the adverse event. Also,

other groups in the hospital will need to implement any new procedures, processes, or changes to

the hospitals risk management plan that results from the RCA.


The chief risk management officer for the hospital would appoint members to the RCA

team. The team should be made up of several members and led by an individual from the risk

management team. The team should consist of members who are from the hospital risk

management department, the hospital quality improvement department, and an uninvolved

person from the department or departments in which the incident occurred. These members need

to be trained in RCA and investigation. A team consisting of these members will be able bring

the perspectives of groups involved in the adverse event. Also, the team members need to be

trusted individuals in the hospital because without trust, the team will not be successful.

Once assembled the team will convene to complete several tasks in order to collect the

information needed and then produce findings, recommendations, and changes to the risk

management plan. Hambleton (2005) suggests that a team review the case records, create a

timeline and interview the hospital staff members and patients involved. The team also needs to

review recent cases to discover if there is a common pattern. By completing such research the

RCA team will be able to identify the root cause and other breakdowns that occurred during the

adverse event. This will allow the organization to prevent errors in the future and improve

patient safety.

Findings

In this adverse event, there were several errors that could have been prevented. The first

error occurred when Jonesky and her husband arrived at the hospital. Jonesky did not speak

English and her husband spoke limited English. The language barrier caused several errors

amongst the hospital staff. First, the hospital staff did not understand the seriousness of

Jonesky’s appendicitis when she first arrived. Jonesky had to wait several hours for care after

being triaged. Jonesky’s husband attempted to talk to the hospital staff after waiting several


hours for care. After Jonesky was moved into an exam room, the nurse understood Jonesky’s

name to be Jones. This incorrect labeling was the root of the problem. If the nurse had properly

labeled the patient as Jonesky, the likelihood of the surgeons and the operating team performing

the wrong surgery would have been significantly reduced. The nurse also failed to verify the last

name with the husband when the nurse could not understand the patient.

Another root of the problem was with the surgeons and the operating team. In the

operating room preparation area, the surgeon and the operating team should have completed their

time out in full. Since it had been a long day, the surgeons and the team were not judicious in

the review. If the time outs had been properly completed the teams would have realized they

were operating on the incorrect patient. Even if the patients were labeled correctly, the patients

do have similar spellings and a judicious time out would have prevented an operating team from

working on the wrong patient.

Another finding is that the hospital staff seemed to be in need of relief or assistance. The

hospital staff needed to bring in the nurses and the physicians that the facility had on call to come

in as relief and assist in the workload. Such assistance from the on call staff would have

lessened the burden on the overworked staff and could have prevented some of the simple

mistakes that were made. A review of the hospital’s culture may be needed because the culture

could be contributing to the errors

Recommendations

At the end of the RCA, the risk management team presents recommendations.

Hambleton (2005) states these recommendations will allow the healthcare organization to take

action. The recommendations include incorporating a language services and following process

procedures.


Language Services

If an interpreter had been available during Jonesky’s visit, then one of the root causes

could have been avoided. With an interpreter, Jonesky could have freely described her problem

to the emergency room nurses and then she could have received more prompt care. Having

access to an interpreter would have helped the Jonesky case. With access to interpreters, the

hospital can improve its customer service and quality management. Flores (2005) writes that

interpreters can improve quality. The hospital will need to evaluate the community it serves and

hire based on the cultures present. However, a hospital may need to serve many languages and

may not be able to afford all the interpreters needed. Having an interpreter service available to

the hospital could help improve services to patients. For example, Certified Languages

International (n.d.) provides healthcare facilities with immediate service and nearly 200

languages. With this type of language service, the hospital can be a better neighbor for its

community and patients. From the beginning, the ER staff was aware of the language barrier and

could have called upon a medical interpreter service. The language service would have followed

the patient through the ER into the OR and assisted the hospital staff with Jonesky’s care.

Procedures and Process

Ralston and Larson (2005) write that when hospitals get away from creating a patient

centered environment, there is a concern for patient safety. In this case study, there are several

instances where the staff does not show concern for the patients. For example, the nurse does

not take time to properly communicate with patients. A hospital that is patient oriented would

have found time to understand the patient.

Shepard (2005) writes that operating teams are required to take a time out prior to surgery

to ensure that the team is operating on the correct patient for the correct procedure and all duties


have been assigned. This provides a process that ensures that the providers do not make a

mistake. In a patient oriented culture, if a team member believes a mistake is about to happen,

then the team member would speak up. The operating team’s failure to complete the time out

process causes the team to provide the incorrect surgery for patient. If the processes and

procedures are followed then the organization can provide a safe environment for patients.

Improving the Risk Management Plan

The hospital needs to incorporate the recommendations into the hospitals risk

management plan to prevent future errors and system break downs. Incorporating the

recommendations from the risk management team, the hospital will be able to prevent similar

adverse events in the future. However, the hospital will need to ensure the risk management plan

provides a clear monitoring, implementation, and evaluation process.

A successful risk management plan has a clear administrative structure that allows for

proper monitoring and implementation (Emergency Care Research Institute, 2010). This gives

the organization’s leadership, particularly the risk management officer, the ability to implement

the risk management plan. Also, department and team leaders in the hospital will know the role

that they and their teams play in the hospital’s risk management plan. An administrative culture

will work to create a trusting atmosphere that is focused on the patient. By doing so, the

hospital’s risk management plan will be successful.

A strong administrative structure will benefit the organization’s risk management plan.

With such a structure, the organization will be able to create an atmosphere where employees can

evaluate the risk management plan. Through the information gathered in the evaluation process,

the organization will be able to assess its weaknesses and strengths. The evaluation will need to

take place at several levels, first through the organization’s senior management and board and


then with department and team leaders. By incorporating all of the organizations management

levels each person will see how they fit into the risk management plan and where improvements

need to be made. If the hospital had monitored and evaluated its risk management plan, it would

have realized a weakness in its language services and the effect of long day on its staff.

Roles

Like many organizations, hospitals have administrators that gave their teams directions,

assign tasks, and ensure their teams provide quality work. Also, working in teams provides a

checks and balances that assist in ensuring patient safety. In this case, there are several team

members that should have felt empowered to prevent the errors. The operating team should have

noticed the potential before they operated, but the case notes show that the team went along with

the surgeon when the time out was cut short. The administrator running the ER should have

worked to get an interpreter when the Jonesky’s arrived.

The role of outside entities and how they influence the hospital’s risk management plan

include purchasers, regulators, and accrediting agencies. The Center for Medicare and Medicaid

Services (CMS) incentives hospitals and other healthcare organizations by providing funding for

those that meet certain levels of care (Johnson, Dawson, & Acquaviva, 2012). CMS is interested

in the processes and the procedures the hospital uses to safeguard its financial resources. This

requires that patients receive appropriate and efficient care and avoid mistakes. The Jonesky

adverse event will cause the hospital to come under review from CMS.

A private accrediting organization that is recognized nationwide is the Joint Commission.

Their accreditation allows hospitals to build a quality reputation in the community. A positive

reputation attracts customers and quality employees. The Joint Commission accredits hospitals

based on patient safety and risk management. The risk management and patient safety programs


required by the Joint Commission would prevent adverse events such as the Jonesky event. The

Joint Commission would also provide the hospital with feedback to improve its risk management

and patient programs.

Regulators of all types want to ensure there is a safe and quality healthcare system. With

the passage and implementation of the Patient Safety and Quality Improvement Act (PSQIA)

Kadzielski and Mitchel (2009) write that healthcare organizations are required to implement

quality controls that meet regulations for providing better safety measures. PSQIA will assist in

creating voluntary reporting and evaluation measures that allow improvements in training that

may be needed. PSQIA will reduce medical errors and improve patient safety.

Conclusion

Hospital need a risk management plans to provide a safe and quality environment for

patients and to prevent errors and patient injury. The case study presented gave an example

where a risk management plan would have benefited the patients and hospital. A variety of

errors caused the hospital staff to perform the wrong surgery on two patients. This paper

evaluated the errors through a root cause analysis and made recommendations to improve the

organization’s risk management plan.


References

Boston Children’s Hospital. (2012). Emergency Medicine. Retrieved from

http://www.childrenshospital.org/clinicalservices/Site1922/mainpageS1922P6.html

Emergency Care Research Institute (2010). Developing a risk management plan: A step by step

approach. Retrieved from

http://bphc.hrsa.gov/ftca/riskmanagement/webinars/handoutrmplan.pdf

Certified Languages International. (n.d.). Medical Interpreter Services. Retrieved from

http://www.certifiedlanguages.com/medical-interpreter

Flores, G. (2005, June). The impact of medical interpreter services on the quality of health care:

a systematic review. Medical Care Research and Review, 62(3), 255-299.

Hambleton, M. (2005). Applying root cause analysis and failure mode and effect analysis to our

compliance programs. Journal of Health Care Compliance, 7(2), 5-12.

Johnson, J., Dawson, E., & Acquaviva, K. (2012). The quality improvement landscape. Ransom,

E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (Eds.), The healthcare quality book:

Vision, strategy, and tools (407-429). Chicago, IL: Health Administration Press.

Kadzielski, M. A., & Mitchel, L. A. (2009). An analysis of the new federal patient safety law and

final rule. Journal of Health Care Compliance, 11(2), 5-16.

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: Building a safer

health system. Washington, D.C.: National Academy Press.

Nicolini, D., Waring, J., & Mengis, J. (2011). The challenges of undertaking root cause analysis

in health care: A qualitative study. Journal of Health Services Research & Policy, 16(1),

34-41. doi:10.1258/jhsrp.2010.010092


Ralston, J. D., & Larson, E. B. (2005). Crossing to safety: Transforming healthcare organizations

for patient safety. Journal of Postgraduate Medicine, 51(1), 61-67.

Shepard, S. (2005, February 13). Surgery 'time out' confirms site, patient, procedure. Memphis

Business Journal. Retrieved from

http://www.bizjournals.com/memphis/stories/2005/02/14/focus2.html?page=all

Documents

Risk Management Plan-Response to an adverse event