module 5 - concise analysis method
DESCRIPTION
The background, key features and main steps of the concise analysis method are described, discussed and applied in this module together with the main tools used during a concise analysis (timeline, guiding questions, constellation diagram, and statements of findings).TRANSCRIPT
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