b3 rapid fire: preventing medication chaos - s. fuller-blamey
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B3: Paying Attention to Near Misses Prevents
Actual Harm
BCPSQC Quality Form 2012
March 8, 2012Sue Fuller Blamey
Background – Near Miss Reporting
• A near miss is defined as an event that could have resulted in unwanted consequences but did not because either by chance or by timely intervention, the event did not reach the patient (CPSI).
• High Reliability Organizations regard near misses as system failures that reveal potential danger or evidence of success since potential harm was avoided.
Analysis of Patient Safety Events
System improvements have a 4-pronged approach:
Reactive: Analysis of actual events with some degree of harmAnalysis of aggregate data
Proactive:Analysis of near miss eventsAnalysis of errors that have occurred in other organizations
Proactive vs Reactive
Looking at these
Can help prevent these
Barriers to Near Miss Reporting MacPhee & Sherrard CPSI
• Fear and lack of belief that reporting results in improvement
• Fear of blame – culture of safety in the organization
• Method of reporting
Fostering a Just Culture for Reporting
•All health care team members must feel that they are contributing to patient safety by reporting
•When organizations pay attention to near misses and put strategies in place to prevent near misses, the number of actual patient safety events will be
reduced.
PHSA Quality & Safety Framework
PHSA VISION, MISSION, VALUES &STRATEGIC PLAN
Str
ateg
ic P
lan
Ena
bler
s: P
rovi
ncia
l Pol
icy,
O
rgan
izat
iona
l Cap
acity
(Org
aniz
atio
nal,
Hea
lth H
uman
R
esou
rces
, Inf
orm
atio
n M
anag
emen
t, In
fras
truc
ture
C
apac
ity, F
inan
cial
Cap
acity
), P
artn
ersh
ips
Peo
ple
Lead
ersh
ip
Effectiveness
Safety Access Efficiency ContinuityPatientCentred
PopulationFocus
Work Life
QUALITY DIMENSIONS
RPIWFMEARCA
SBARPSLS
ProtocolsGuidelines
CCMsStandard work
Checklists
High Reliability Organization
CommunicationReporting Measuring Evaluation
Sustainable Health Care
PATIENT & FAMILY
Standards Methods Outcomes
Accreditation ROPs
Culture of Quality & Safety
Cross-cutting themes – Quality & Safety, Learning and Research
Cross-cutting imPROVE Management System
SUSTAINABLE QUALITY PATIENT OUTCOMES
VALUE FOR THE PATIENT
PHSA QUALITY & SAFETY FRAMEWORK
PHSA Near Miss Project
• Educate staff about Near Miss Event reporting
• Analyze all of Near Miss Events per year
• Identify trends and 2 – 3 projects per agency per year
• Create improvement project teams
• Develop and implement solutions to prevent recurrence of same type of event
• Sustain gains
Types of PHSA Near Miss Event Projects
Two identifiers Physicians Verbal Orders
Dangerous Abbreviations Accurate Laboratory Reports
Medication Preparation Handovers & Transitions
Prevention of Unprocessed Orders
Morphine Dosing Errors
Mislabeled Specimens ID of Patient with Mental Health Concerns
Medication Reconciliation Documentation
PHSA Actual vs Near Miss Patient Safety Events
BC Cancer Agency Near Miss Reporting
BC Centre For Disease Control Lab Project
PHSA Patient Safety Events
PHSA Patient Safety Events Category of Event - Behaviour
BC Women’s Nitroglycerine Project # of Medication Events
BCCA Prevention of Unprocessed Orders Leading to Missed Chemotherapy Appts
BCCA Prevention of Unprocessed Orders
% of Physician Order Defects
0%
10%
20%
30%
40%
50%
60%
70%
80%
Month
% o
f P
hysic
ian
Ord
er
Defe
cts
% of Physician OrderDefects
BC Children’s Patient Identification Project
BCMHAS – Forensics & RVH Medication Administration Process Project
Forensics # of Medication Events d/t Med Administration Issues
0
5
10
15
20
25
30
2009 2010
Year
# of
Eve
nts Near Miss
Actual
Riverview # of Medicaton Events d/t Med Admin Process
0
10
20
30
40
50
60
70
2009 2010
Year
# of
Eve
nts
Near Miss
Actual
PHSA Medication Patient Safety Events
