Download Lessons Learned From Root Cause Analysis Activity

In Search of the Root
Cause:
Patient Safety at UCSF
Adrienne Green, MD
Associate CMO
Clinical Professor of
Medicine
Kathy Radics, RN,
MPA
Patient Safety
Manager
GME Grand Rounds
October 19, 2010
Case Presentation
A 45 y/o M underwent a cardiac
catheterization. While in the recovery area, he
complained of feeling lightheaded and had
labile blood pressure. He was therefore
transferred to the Limited Stay Unit for
overnight observation.
The attending physician was unaware of the patient’s
admission.
The next morning he complained of severe
abdominal pain.
The LSU nurses had difficulty identifying a provider to
evaluate the patient.
Case Presentation
The patient was hypotensive, CBC with H/H
of 7.2/21.4. He was taken to the ED CT
scanner where he arrested. A code was
called and the patient was taken to the OR.
The code was called before surgical
intervention.
The patient died of an unrecognized retroperitoneal
bleed.
Objectives
• Review the role of RCA in promoting patient
safety
• Describe the RCA process
– Background
– UCSF process
– Evidence for RCA effectiveness
• Review recent UCSF events
• Review strategies for disclosure/what do after
an event
Patient Safety- some definitions
• Sentinel Event
– A preventable error leading to death, serious physical
or psychological injury, or risk of such injury
• Adverse Event
– A preventable error leading to any level of injury
• Active Error
– Occurs at the point of human interface with a
complex system
• Latent Error
– Failures of system design
Strategies to Improve Patient Safety
• Root Cause Analysis
– Introduced to medicine in early 1990s
– Mandated in 1997 by The Joint Commission for all
sentinel events
• Failure Mode Effects Analysis- prospective
• Incident Reporting Systems
• Patient Safety Rounds
• Culture of Patient Safety Surveys
Root Cause Analysis
• safe, blame-free, protected
• structured retrospective analysis for identifying
causal factors
• multidisciplinary
• focuses on systems and processes, not individual
performance
• ask why at each level of cause and effect
• identify and implement improvement actions to
prevent recurrence
• Also at UCSF
– assign accountability for action items and timely follow up
– discuss disclosure to patient/family
– discuss bill waivers
Root Cause Analysis
What happened?
Why did it happen?
What do we do to prevent it from
happening again?
Not allowed at an RCA:
• “it’s okay, the patient was really complex and
sick anyway”
• “that MD/RN/pharmacist just wasn’t doing
his/her job”
• finger pointing
RCA at UCSF
• Conducted as part of the UCSF Patient
Safety Committee (PSC), a multidisciplinary
Medical Staff Committee
– RN, MD, Pharmacy
– Adult and Children’s Hospital
– Leadership/Administration
– Risk Management
– Front line providers
– Content experts
What kind of events lead to RCA at
UCSF?
• “Never events”
• Sentinel events
• Errors resulting in patient harm
• Near misses
• Other events requiring multidisciplinary review
2010
Example
Event Type
2009
Procedural
Complications
35.5%
38.5%
Esophageal Intubation
Medication Errors
22%
27 %
Insulin pen used for 2 patients
Device Events
8%
0
Thermal Injury (burn) due to
cooling device
Q1-3
Specimen Issues
6.6%
0
Incorrect number of path
specimens sent from OR to
path
Treatment Delay
6.6%
11.5%
Delay in appt to f/u on abnl
PSA
Nosocomial Infection
6.6%
4%
Hospital acquired H1N1
Wrong Site Surgery
4%
0
Wrong eye
Retained Foreign Body
4%
7.5 %
Retained sponge
Other
6.6%
11.5 %
Fall with injury
RCA Actions and Follow-up
• Identify and implement improvement actions to
prevent recurrence
– assign accountability for action items
– team leaders report to PSC on progress
Hierarchy of Actions
Stronger Actions
–
–
–
–
–
Physical plant changes
Engineering control (forcing
functions)
Simplify the process and
remove unnecessary steps
Standardize equipment,
process, caremaps
Leadership in support of
patient safety
Weaker Actions
–
–
–
–
Double checks
Warnings and labels
New procedure,
memorandum, policy
Training
Intermediate Actions
–
–
–
–
–
–
Increase staffing/decrease
workload
Software modifications
Eliminate/reduce distractions
Checklist/cognitive aid
Read back
Enhanced
documentation/communication
http://www4.va.gov/ncps/CogAids/RCA/index.html#page=page-14
Actions: Strong or Weak?
Action Items: Themes
Corrective Action Plan Types
Adequacy of technological support
Oct - Dec
09
Jan - March
10
April June 10
July - Sept
10
1
1
2
1
3
1
6
7
1
1
6
2
2
Availability of information
Behavioral assessment process
Care planning process
6
Communication among staff members
Communication with patient / family
1
Competency assessment / credentialing
2
1
Continuum of care
1
3
Equipment maintenance / management
3
4
3
Medication management
2
6
5
4
Orientation and training of staff
3
3
2
2
Policies
2
1
1
2
Staffing levels
2
2
2
1
Patient identification process
Patient observation procedures
Physical assessment process
Physical environment
Supervision of staff
Total
1
22
34
19
24
Could This Happen To One
of Your Patients?
Case #1: Attending Oversight
A 45 y/o M underwent a cardiac catheterization.
While in the recovery area, he complained of feeling
lightheaded and had labile blood pressure. He was
therefore transferred to the Limited Stay Unit for
overnight observation.
The next morning he complained of severe
abdominal pain.
The patient was hypotensive, CBC with H/H of
7.2/21.4. He was taken to the ED CT scanner where
he arrested. A code was called and the patient was
taken to the OR. The code was called before surgical
intervention.
The patient died of an unrecognized retroperitoneal
bleed.
Case #1: Root Causes
• The attending physician was unaware of the patient’s
admission.
• The LSU nurses had difficulty identifying a provider
to evaluate the patient.
• While in the LSU the patient had an acute change in
condition
– there was confusion by the nursing staff about whom to
call for assistance.
– the attending physician was not notified
• There was a failure to recognize a potential
retroperitoneal bleed
Case #1: Actions
• Attending oversight guidelines developed
• Education on post-cath complications for involved
providers and units
• LSU developed clear protocol for escalation
• Could this happen to one of your patients?
– Are you comfortable calling an attending with questions
regarding patient care?
– Are you familiar with your service’s attending oversight
guidelines?
Guidelines for Attending Oversight on the Pediatric Medical Services
Department of Obstetrics, Gynecology and Reproductive Sciences
Trainee/Attending Communication Guidelines
June 2010
Case #2: Medication Error
A 6 mo baby with ALL received chemo including
methotrexate. 2 days later she developed fevers and
was empirically started on zosyn.
Due to poor mtx clearance with high levels, the pt
developed mucositis requiring TPN and prolonged
hospitalization.
Medication Error: Root Cause and
Actions
• The ordering MD was unaware that PCNs are
contraindicated until mtx levels decline
Weak
– Education and training
• The fever occurred at night and the signout/handoff
did not indicate which abx the pt could or could not
have
– Peds Onc sign-out modified to include list of meds to avoid
• The pharmacy did not catch the drug interaction
because mtx was no longer on the pt’s med profile
– A “fake order “ was developed and implemented by
pharmacy to maintain mtx on pharmacy profile until levels
decline
Strong
Case #3: Wrong Site Surgery
A patient was consented for a left eye surgery. The left
eye was marked in the pre-op area. The pt was prepped
and draped in the OR. The initial incision was made on
the right. A member of the team then mentioned that a
time out had not been performed and that the surgery
was to be on the right. The correct surgery was then
performed.
Wrong Site Surgery: Root Cause and
Actions
• The correct site was marked in the pre-operative area
but
draping covered the site marking
– Ophthalmology changed practices w/r/t marking and
draping
• A time out was not performed
– Re-education re: universal protocol and checklist
– Staff empowered to escalate noncompliance
Could this happen to one of your
patients?
• Are you using the
correct checklist
form?
• Do you perform a
comprehensive
timeout before each
procedure? Does
your time out include
the entire team?
Case #4: Equipment Not Sterilized
• Dirty equipment was re-used in an outpatient clinic
procedure
Dirty Area
Clean Area
Equipment Not Sterilized: Root Cause
and Actions
• Sterilization equipment in procedure room; dirty and
clean equipment in close proximity
– Sterilization moved to SPD
– Extra equipment purchased to enable this new practice
• Sterilization procedures and competencies not
standardized b/w SPD and clinics
– Sterilization practices and competencies standardized b/w
clinic staff and SPD
Case #5: IV Infiltration
• Event:
– A patient developed significant skin injury from an IV
infiltrate of nafcillin
• Root Cause:
–
–
–
–
The IV was placed in patient’s foot
The site was covered by kerlix
The medication being infused was caustic
Patient was unable to have a PICC placed in a timely
manner
IV Infiltration: Root Cause and Actions
• Action:
– A multidisciplinary taskforce convened to establish
standard practices/guidelines for IV placement, including
escalation to more skilled providers and a PICC if
necessary
– Education re: caustic meds
– Establish procedures for response to IV infiltrates
• Could this happen on your team?
– Do you order PICC lines when appropriate?
– Do you know how to care for an IV infiltrate?
– Do you know which medications are caustic and should not
be infused through a PIV?
Device Fire
• Event:
– An x-ray developer caught fire
• Root Cause:
–Equipment was old with unclear history of inspection and
maintenance
–Difficulties with response to fire
• Action:
–New digital developers were ordered
–Complete fire safety assessment of the site
–Staff re-training re: fire and safety
• Could this happen on your team?
–Have you reviewed fire safety responses recently?
–Do you red tag faulty equipment to be sent to biomedical
engineering for repair?
RCA Effectiveness
• 3 studies show improved outcomes from single
RCAs (improved mortality, graft survival)
• 8 studies measure process outcomes
(compliance with new process, survey
perception of improvement)
• Retrospective VA study (119 actions/26 RCAs)
– 39% actions fully implemented (74% of those
effective)
– “stronger” actions more likely to be implemented, 75100%
– more “weak” actions recommended but <30%
implemented
Percarpio et al. Joint Comm Journal July 2008
Hughes. NCPS Topics in Pt Safety 2006
RCA Effectiveness at the VA
Root Cause/Contributing
Factor
Pre-RCA
Post-RCA
None
10%
0
Patient Behavior
43%
10%
Course of Disease
40%
3%
Systemscommunication,
equipment etc.
37%
100%
Bagian et al. Journal on Quality Impr. 2002
RCA Effectiveness at UCSF:
Sustainability
• Analysis of actions from 2007 and 2008
• Random selection of 10% of actions from top 3
action categories (med management,
communication, orientation/training)
• Action completed and sustained
58%
• Action completed and abandoned
17%
• Completed but recurrent event
17%
What do I do if an error occurs in one of
my patients?
• Call your attending
• Speak with the patient and family
– Express empathy and apology
– Inform of the facts but don’t speculate
– Let pt/family know that the event will be investigated
and identified problems fixed
– Let pt/family know that you will stay in contact as you
learn more
• Document objectively
• Call Risk Management (353-1842)
• File an Incident Report
RCA at UCSF: Opportunities for
Improvement
• Implement improvements beyond the location of the
primary event
• Demonstrate sustainability of improvement activities
• Disseminate learnings and themes beyond the
location of the primary event
Summary
• RCA is an important tool for improving patient safety
What happened?
Why did it happen?
What do we do to prevent it from happening again?
• UCSF has a robust and improving RCA process
• Recent events highlight the importance of:
– Resident:attending communication/oversight
– Medication management
– Universal Protocol
• Help is available if an error or adverse event occurs in one
of your patients
Suggestions and Comments
• Adrienne Green [email protected]
• Kathy Radics [email protected]