Incident Analysis Learning Program - Module Five

Concise Analysis Method

January 31, 2013

Welcome

Sandi Kossey Ioana PopescuErin PollockTina Cullimore Nadine Glenn

What happened?

How and why?

What can be done?

What was learned?

Learning Program

Comprehensive

Concise

Multi-incident

Learning Objectives

• The similarities and differences between a comprehensive and concise individual incident analysis

• The main steps in conducting a concise analysis

• Give examples or scenarios of incidents where concise analysis is recommended

Agenda

3-parts• Knowledge expert + Q&A

• Practice leader + Q&A

• Facilitated discussion or Q&A

6

Introducing: WebEx

Apr 8, 2023 6

Be prepared to use: - Raise Hand & Checkmark

- Chat & Q&A

- Pointer & Text

About You

0 Experience with [any] CONCISE analysis 10

Presentation

Carolyn Hoffman

Background and Features

Need for a “concise” method• Informal (mini-RCA) Formal (NPSA, M&M)

Consistent with the principles and methodology of analysis

Conscious and deliberate decision to focus on the: • Agreed-upon facts• Key contributing factors and findings• Actions for improvement (if any)• Evaluation

Concise and Comprehensive

Action Concise Comprehensive

Include person(s) with knowledge of IA, HF, solutions development

Facilitated by an individual with input from patient, local staff & physicians

Conducted by an inter-disciplinary medium to large ad hoc group (includes also external experts / consultants) facilitated by a knowledgeable individual.

Time taken for analysis Short

(hours-days)Longer

(45-90 days)

Identifies contributing factors as well as remedial action(s) taken (if any) and recommendations for improvement

Principles of Incident AnalysisReflects intent Incorporates all

principles

Evaluation Component

Page 46 Canadian Incident Analysis Framework

Case: Medication Incident

Setting: Community hospital & busy home care services

Current process: hospital faxes referrals to fax line if 9-5, M-F, home care coordinator reviews faxes & accesses the home care central record schedule home care visits if outside business hours home care nursing staff periodically check faxes sorts by ongoing and new clients referrals for ongoing given to responsible nurse pharmacist dispense meds from drug stores in the community. some attending physicians at comm. hosp fax prescriptions to patients’ drug store for ease of pickup

IncidentClient (discharged from hospital with meds) found in bathroom. Moderate amount of bright red blood. Transfer to ED.

WHAT HAPPENED?

Case: What Happened

Based on the• incident report • a review of the home care record• hospital chart• referral form

…the facilitator responsible to conduct this concise analysis started to draft a timeline of the incident.

Timeline confirmed and expanded by• Interviews with the client, pharmacist and RNs, • Examination of the drugs involved in the incident

Case: Timeline

Example (p.113)

HOW AND WHY IT HAPPENED?

Analyze Information

• Use guiding questions to briefly explore all categories (Appendix G, Page 89)• Use some questions or develop incident specific

questions to informally discuss the incident with those involved and external experts

• Ask• What was this influenced by?• What else affected the circumstances?

• Use constellation diagram• Systemic approach• Visual representation • Linkages

• Summarize findings

Case: How and Why

Case: FindingsWork environment

• The lack of a standardized home care risk assessment tool or protocol increased the likelihood that clients discharged from hospital back to the community would not be accurately triaged to ensure appropriate and timely home care services are provided.

Patient• The deterioration in the client’s physical and cognitive

abilities increased the likelihood of a medication error in his self medication management.

Care team and organization• The lack of a formalized, system-wide and communicated

Discharge Medication Reconciliation process (including an updated Best Possible Medication History) decreased the likelihood that the client would receive the appropriate and timely support required for safe medication management.

WHAT CAN BE DONE…?

WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER

Case: Recommended Actions

Case: Follow-through

WHAT WAS LEARNED?

The ultimate objective of analysis

Feedback• To the organization: patient family, those

involved in the incident, the analysis team, etc

Feed-forward• Externally to prevent similar incidents from

occurring in other organizations, systems, countries

• Informing the public and/or media

Questions?

Real-life Experience

Gordon Luy

Safety at Home: A Pan-Canadian Home Care Safety Study, Root Cause Analysis Sub-Project

- Project #4 – Falls by Home Care Clients (Canadian Patient Safety Institute)

Gordon Luy, BSW, MSWPatient Safety ConsultantWinnipeg Regional Health AuthorityQuality Improvement & Patient Safety Unit

Safety At Home StudyLed by Dr. G. Ross Baker of the Institute of Health Policy,

Management and Evaluation, at the University of Toronto.A qualitative study to investigate the root causes and contributing

factors that lead to {Falls-; Medication-} related adverse events suffered by patients in home care, and help to form recommendations to prevent similar events in the future.

The study was conducted at three provincial sites: Alberta Health Services - Edmonton Zone Home Living Portfolio.Winnipeg Regional Health Authority Community Care Access Centres (CCAC) of the Greater Toronto Area (GTA)

Winnipeg Regional Health Authority Quality & Patient Safety Unit Part of the Research and Applied Learning

Division of the WRHA 3 Units in division

Health Information Services Research and Evaluation Quality Improvement & Patient Safety

WRHA Quality Improvement & Patient Safety Unit

• Under the Chief QIPS Officer• Composed of 3 teams each under a regional

Director: o Clinical Office of Patient Safety: 2 Analysts; and, 1

Auditoro Quality Improvement Team: 7 Quality Managers; 2

Coordinators; and, 3 Analystso Patient Safety Team: 8 Patient Safety Consultants;

1 Patient Safety Pharmacist; and, 1 Education Consultant

WRHA Patient Safety Consultant

A Patient Safety Consultant (PSC) works in collaboration with healthcare sites/settings/program leaders and other members of the Quality and Patient Safety Unit to facilitate the development, implementation and maintenance of the quality and patient safety strategy.

Through system safety reviews (Critical Incident Reviews), PSCs assist staff and physicians throughout the Region to gain an understanding of the complex systems in which people work for potential healthcare system improvements.*

* The Regional Health Authorities Amendment And Manitoba Evidence Amendment Act (2005)

Safety At Home:Sub-Project #4 – Falls by Home Care Clients

Five specific Home Care cases were selected from the Manitoba site (WRHA) for a detailed review using the CPSI Concise Methodology.

The review included interviewing caregivers, managers, clients and their families regarding events related to a fall which occurred during the period of time that the client was receiving Home Care.

CPSI Concise Analysis MethodologyI. Understand WHAT HAPPENED:

i. Information gathering (medical records; interviewing clients, case coordinators and direct service providers (nurses, health care aides)

ii. Construct a a brief timeline.II. Analyze information to identify contributing factors and the relationships among them:

i. Systems theory and human factorsii. Describe the incident and outcomeiii. Identify and define relationships between potential contributing

factorsiv. Formulate findings

III. (Develop and manage Recommended Actions)

The final report contains the facts, contributing factors, a brief context analysis, and where applicable, recommended actions and a plan for evaluation and dissemination.

I. Understand WHAT HAPPENED:

1. We reviewed the client’s medical record: (assessments; client characteristics (e.g. co-morbidities), medications and changes; equipment; professional consultation; process(es) of care delivery (e.g. history, frequency and purpose of visits); circumstances of fall; etc.

2. We interviewed: - Clients (and family): (recollection of event, factors (e.g. environment – photos taken), services)- Case coordinators: (organization, policies, care plan; roles, workload, resources, training, communication, etc.)- Direct service providers (nurses, health care aides): (roles, workload, scheduling, resources, etc.)

3. We constructed a brief timeline (chronology) of event

Incident Analysis – Systems Theory

Human Factors: how humans interact with the world around them. Human error is viewed as a symptom of broader issues within what may be a poorly designed system, such as an adverse physical or organizational environment.**

A system is described as the coming together of parts, interconnections and purpose.*

* Institute of Medicine. Crossing the Quality Chasm: A new health system for the21st century. Washington, DC: The National Academy Press; 2001.** Dekker S. The Field Guide to Human Error Investigations. Aldershot, UK: AshgatePublishing; 2002.

II. Incident Analysis

• Task (care/work process)• Equipment• Work environment• Patient (client) characteristics• Caregiver• Care team (direct service providers and support

team)• Organization (policies, culture, capacity-resources)

Constellation Map of Contributing Factors

Case Example

• Equipment: Motorized wheelchair; manual wheelchair; hospital bed; transfer poles in bedroom and bathroom; bath seat; Hoyer Lift and slings; Life line.

• Work environment: Customized private bungalow; guide dog; client alone at times.

• Patient characteristics: Parkinson’s Disease; chronic back pain and hip pain; physically compromised; alert & oriented but at times has impaired judgment and memory issues; quiet and slurred speech; functional hearing; wears glasses.

Factors of Influence in Event

Environment: The client and family prefer that the client lives in the residence as long as possible. While cared for by extended family and through Home Care much of the day, there are periods of time when the client is alone. Due to compromised judgment and toileting issues, the client may attempt to transfer when assistance not available which has led to falls in the past and increases the risk for a fall.

Equipment: Motorized wheelchair: client sits too far forward and does not use the seatbelt.

Client: Lack of leg strength to push self back in the seat of the motorized wheelchair. Seating position increases the risk for a fall. Motorized wheelchair is preferred for mobility over the manual wheelchair even though the seating position is safer in the manual wheelchair. Risk for a fall is increased if the client falls asleep in the wheelchair - tendency to fall asleep is exacerbated by medications. Also, the client at times attempts to reach or ambulate without assistance present.

Summary Statements/Findings

•The client is more at risk for a fall when using the motorized wheelchair, than the manual wheelchair, due to the seating position in the motorized wheelchair and consequent inability to use the seat belt.

•Preference for using the motorized wheelchair at home predisposes the client to this risk especially if the client falls asleep while in the wheelchair or forgets that he/she in the wheelchair.

•The tendency to fall asleep is exacerbated by medications prescribed to address medical conditions.

•The Home Care services provided were maximized according to the funding formula.

Report Format• Date of Event• Date Event was discovered• Brief Description of event• Date Event Analysis process was initiated • Date Event Analysis process was completed • Describe what Home Care Services received prior to the fall.• Describe what Home Care Services received after the fall • Describe the Client’s primary and secondary medical conditions.• Does the Client live alone?• The extent of harm as assessed 24 hours post event.• Outcome of event• Additional Issues• Medications and how related to event• Chronology• Constellation Map• Identification of factors that contributed to the occurrence of this

event• Summary Statement

Reflection• CPSI Concise Methodology – Very similar to the what we have been using in the

region to review some Critical Incidents (falls and pressure ulcers).

– Is a useful framework for the review of an adverse event of limited harm to the patient (client): • Conceptualizing; • Planning;• Conducting; and • Documenting.

Questions?

Learn from Each Other

Options

1. Learn from each other • Suggested topics

o Do you use concise now? For what cases?o Is it helpful? How long it takes? How is it done? o How did you get started? How did you spread it?

2. Q&A with the 2 presenters

Some participants will “move” to breakout rooms

Breakout Session

Some participants will stay in the main room

- No phone next to your name

- Say no when invited to breakout

Large Group De-Briefing

Highlights from small group discussion

Nuggets from the Q&A

Recap and Next Steps

End of session evaluation; Follow up survey

• Follow-through and share what was learned

March 28, 2013

• Recommendations management

March 7, 2013

• Multi-incident analysis February 21, 2013

Resources

Learning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningProgram/Pages/Session-Recordings-and-Documents.aspx

National Health System – UK• Three Levels of RCA Investigation – Guidance• Example concise RCA investigation reports

Incident Analysis Tools http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Pages/Tools.aspx

Thank YouMulţumesc