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ASK.LISTEN.TALK Walk through – NEW Canadian Incident Analysis
Framework
May, 2012
Hugh MacLeod
Canadian Partners
Learning Objectives
• Incident analysis framework
• Need
• Link with incident management
• Link with reporting and learning
CARE
Care Is - the interaction among our assets
both technological and human.
Care Outcomes – the result of the interaction
between patients and provider.
Care Delivery – the way providers interact
with each other.
ASK LISTEN TALK
New Care Conversations about:
Context is everything
Denial is our greatest threat
Relationships is key
Patient Voice must be heard
Overarching Goals
To enhance the safety and quality of care.
To promote a culture of safety
To promote patient centred care
To encourage learning
To increase effectiveness of investigation
To promote the success of incident analysis
a tool in preventing and or mitigating harm.
Aims
A structured process that aims to identify:
What happened?
How and why it happened?
What can be done to reduce the risk of recurrence
and make care safer?
What was learned ?
Language matters: The International Classification for Patient Safety
A language developed by the World Health Organization for the global patient safety community
WHO Family of International Classifications – International Classification of Disease (ICD)
– International Classification of Functioning, Disability, and Health (ICF)
– International Classification of Health Interventions (ICHI)
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Preferred Terms
Healthcare Associated Harm: • Harm arising from or associated with plans
or actions taken during the provision of healthcare, rather than an underlying disease or injury.
Patient Safety Incident • Preventable and unnecessary harmful, no
harm, near-miss incidents, and reportable circumstances.
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Preferred Terms
Harmful Incident
• A patient safety incident that resulted in harm to the
patient
• Replaces “adverse event”
No Harm Incident
• A patient safety incident that did reach the patient but
did not result in harm
Near-Miss
• A patient safety incident that did not reach the patient
• Replaces “close call”
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Preferred Terms
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Patient Safety
Incidents
Reportable
Circumstances
Harmful incident
(unnecessary harm )
No harm incident
(no harm, but reached the patient) Patient Safety Incidents
Near miss
(no harm, and did not reach the patient)
Healthcare Associated Harm
Methods for Analysis
• The draft Canadian Framework provides two methods for reviewing individual incidents (comprehensive and concise) and one method for reviewing multiple incidents or reviews (aggregate).
• All incident analysis methods aim to determine what happened, how it happened, and what can be done to make care safer.
Comprehensive
• Used for complicated and complex incidents that resulted in catastrophic/major harm, or the significant risk thereof.
• All relevant sources of information are consulted, (interviews supplemented by a literature review).
• A significant amount of time and resources
• Final report will include : • detailed chronology of the facts,
• contributing factors and their influences,
• findings from the literature search/environmental scan,
• context analysis,
• recommended actions, and where applicable implementation,
• evaluation and dissemination plans.
Concise
• Succinct yet systematic way to analyze incidents with no, low or moderate severity of harm;
• Generally the incident and analysis process are localized to the unit/program where care was delivered.
• Sources of information consulted are the available reports, supplemented with a small number of select interviews and a targeted review of other sources of information.
• Analysis is completed in a short interval of time by one to two individuals
• Report contains • the facts (including a brief timeline),
• contributing factors,
• a brief context analysis, and
• where applicable, recommended actions and
• a plan for evaluation and dissemination.
Aggregate analysis
• review of a group of completed analyses (usually comprehensive) of similar incidents. Aggregate analysis can require significant investment in both time and resources, but generates valuable organizational and/or system-wide learning that cannot be obtained through any of the other methods.
or
• review of a group of several similar incidents (in terms of composition or origin) that took place at any location in the organization (possibly in a short interval of time). Incidents selected typically have not been previously reviewed in detail.
Principles
Safe and just culture
Consistency and Fairness
Team Approach
Confidentiality
Voice of the Patient
Concepts
- Human factors
- System levels
- Complexity
- Context
Framework
Continuum
– Reporting
– Analysis
– Management
Inter-connections
When To Use Framework
Not appropriate for all types of analyses
Following types of incidents are not
recommended.
1. Events to be the result of a criminal act
2. Provider intended to cause harm
3. Acts related to substance abuse
4. Patient abuse of any kind
Improving Care Alliance
• Group of organizations that generate and share their patient safety and quality improvement related content on the Improving Care Search Centre in two ways
• Website will be indexed in search tool
• They will be able to feature themselves by sharing information on the Patient Safety Crosswalk
• The Patient Safety Crosswalk now becomes a promotion tool for Alliance members
What is the Improving Care
Search Centre?
• Google-like search centre with personalized
news feeds and a search tool that searches
specifically selected websites (CPSI and
Improving Care Alliance Members).
How does it work?
3. Personalized feeds
4. Featured Content
1. Search Tool
2. Login (Optional)
Tools and Templates
Team management checklist
Challenges and Strategies during the process
Team member roles and responsibilities
Sample Team Charter
Sample Confidentiality Agreement
Incident Analysis Guiding Questions
Incident Report Template
Creating a Constellation Diagram
Example of Constellation Map
Incident:
Outcome:
Task
Equipment
Work
Environment
PatientCare Team
Organization
System
Other
Factor
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Actionable
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Actionable
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Actionable
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Actionable
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Actionable
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Actionable
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Actionable
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Actionable
Factor
Incidental
Finding
Incidental
Finding
Incidental
Finding
Incidental
Finding
FactorFactor
Case Studies
Comprehensive Analysis – Elopement from a
Long Term Care Home
Concise Analysis – Medication Incident
Three Human Factors Methods
Cognitive Walkthrough
Heuristic Evaluation
Usability Testing
For more information
Ioana Cristina Popescu
780-498-7268
www.patientsafetyinstitute.ca
Targeting – June 2012 for Publication
THANK YOU!