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Reporting, analysis and feedback of adverse events including RCA and other analysis methods

This article discusses that just culture is balance between holding organizations and individuals accountable for implementing safe practices and change in the workplace. This is especially important in healthcare settings to decrease patient mortality and increase patient safety. Benefits of fostering a just culture include increasing effective communication and innovation across various departments.


Sidney Dekker, PhD supervises the Safety Science Innovation Lab at Griffith University in Brisbane, Australia. In Dekker’s book, Just Culture: Restoring Trust and Accountability in Your Organization (3rd ed.), he discusses how to effectively create a just culture of accountability and responsibility. This includes learning strategies on how to appropriately approach adverse incidents such that knowledge is maximized and the negative effects are minimized.

 


Meeting/Conference Proceedings
Meeting/Conference Proceedings
Northwest Communication and Resolution Program Leader Retreat, Sept 2017

The Collaborative for Accountability and Improvement and the Foundation for Healthcare Quality hosted a two-day retreat in Seattle, Washington (09/2017) in which administrators and healthcare providers discussed ways to advance communication and resolution programs (CRPs) and other resources in Northwest Hospitals to increase patient safety and communication among hospital leadership, attorneys, and health insurers.


Communication-and-resolution programs (CRPs) are used by healthcare providers, administrators, and insurers to effectively communicate with and apologize to patients in the wake of adverse incidents; to investigate the occurrence; and offer compensation if appropriate. Researchers examined the effects of CRPs in two community hospitals and two academic medical centers in Massachusetts. They analyzed surveys and recorded data gathered by program members and clinicians at the hospitals. Researchers concluded, that CRPs are effective in increasing patient safety, but there were some barriers in implementing these programs. Barriers included lack of patient participation in disclosing data, as well as some compensation needs not being fulfilled.


Alberta Health Services (AHS) adopted the Patient and Family Centered Care (PFCC) program to increase patient and family engagement in the healthcare settings. The PFCC encourages and trains patients, families, and healthcare workers to share their experiences and improve care. This program also offers methods to measure the effectiveness of this program.

 


Marx discusses uses a legal viewpoint to discuss how to be more tolerant of errors in the workplace, while also holding people accountable for their mistakes. He outlines four important behavior concepts, and how they can be applied to the healthcare system to decrease risk of adverse events and increase accountability: malpractice, understanding violations, ignorance, and mishaps.


Journal Article
Published articles related to CRP
Patients as Partners in Learning from Unexpected Events

Patients and family members identified the factors that contributed to their respective adverse incidents, such as not following safety measures and lack of communication. Participants stated that they were not involved in the analysis process of the adverse events, so they missed out on ways to become more involved in learning about adverse events and how they can be decreased in the healthcare setting. Thus, the authors of this article emphasize that healthcare systems should implement educational modules that not only help decrease the risk of adverse events, but also teach healthcare professionals, patients, and family members on how to be proactive in preventing them.

 


Case Study
Journal Article
Published articles related to CRP
Patients’ Experiences With Communication-and-Resolution Programs After Medical Injury

Communication-and-resolution programs (CRPs) were developed so healthcare organizations and liability insurers could effectively communicate with patients about adverse incidents, use methods to increase patient safety, and offer compensation when appropriate. However, this study found that healthcare organizations did a poor job on communicating with patients and families on how to prevent adverse events. Overall, this study emphasized how patients and families wanted hospitals to be more efficient in not only disclosing adverse incidents, but also being more efficient in preventing them.

 


Journal Article
Published articles related to CRP
Personal accountability in healthcare: searching for the right balance

Authors of this article emphasize how the “no blame” approach should be balanced with accountability when promoting patient safety in healthcare settings. However, this balance should be distributed among healthcare professionals, patients, and family members when effectively improving and promoting patient care and safety.

 

 


In this study, conference and process leaders were divided into three groups Morbidity and Mortality Conferences (MMCs), Educational Conferences, and Quality Assurance (QA) Meetings) to review adverse incidents and near misses, as well as to find ways to prevent them in the future as well as to promote patient safety. Researchers found that it is important to incorporate various approaches and clinical practices to effectively promote patient safety in the healthcare setting.

 


Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
PSNet: Root Cause Analysis

Root cause analysis (RCA) is a systematic method used to analyze adverse incidents, especially in the healthcare setting. This approach identified both active and latent errors that contribute to adverse incidents. Active errors occur between humans and the system, while latent errors are known as the hidden issues in a healthcare system. An important principle of RCA is to recognize the source of problems that contribute the increased risk of medical errors, while not concentrating on individual mishaps as the sole cause of the issue.

 

 


Journal Article
Published articles related to CRP
Psychological Safety and Error Reporting Within Veterans hospitals

Previous studies suggest that psychologically safe workplaces foster a feeling of comfort among employees, allowing them to feel comfortable with taking risks, such as identifying mistakes in the workplace. In this study, researchers analyzed the levels of psychological safety in Veterans Health Administration (VHA) hospitals, and studied its relationship to employees’ comfort in disclosing medical mistakes. Researchers found that only a minority of workers were uncomfortable in admitting mistakes, and their discomfort was due to fear of retaliation.

 


Journal Article
Published articles related to CRP
RCA2: Improving root cause analyses and actions to prevent harm

The National Patient Safety Foundation (NPSF) published this report on root cause analyses and actions (“RCA2”), which are programs aimed to reduce the risk of adverse medical events and instead increase effective measures to reduce them in the future. This report illustrates strategies that healthcare organizations can utilize when implementing RCA2 programs in the workplace. This report also details specific strategies that help healthcare organizations identify the faults and hazards in their systems that increase the risk of adverse medical outcomes, as well as how to take active and positive steps to prevent them from happening in the future.

 

 


Book/Report
Reference to book or report
RCA²

The National Patient Safety Foundation conducted a study to investigate the effectiveness of root Cause Analyses and Actions, or RCA2 (RCA “squared”), in healthcare settings. RCA2 is a model used by health professionals to understand why mistakes occur in the workplace, and how to develop strategies to prevent them in future situations. National Patient Safety Foundation specifically concentrated on the specific methods used by the RCA2 model, and analyzed if they were effective or not. They also identified defects in the model and sought out ways on how to improve them, so they model could be efficient.

 


Researchers concluded that an organizational culture characterized by anonymity, rewards and recognition for staff members making reports, grassroots involvement in the review and interpretation of data, and use of external sources of error data is critical for establishing a process truly capable of creating safety. This process for changing culture can be applied in any health care system desiring to improve the safety of the medication use process.

 


The authors of this article analyzed how medical mistakes and injuries are correlated with high healthcare costs and poor patient quality. To lower these rates, the authors emphasized the importance of implementing an incident reporting system in healthcare settings. The implementation of these systems involve changing the culture of the workplace, so it promotes learning, flexibility, and blamelessness.

 


Journal Article
Published articles related to CRP
Respectful Management of Serious Clinical Adverse Events

A serious clinical adverse event is a crisis for everyone involved. Governing bodies and executive leadership carry the burden of these events forever, but carrying the burden isn’t enough. They also have a responsibility to ensure that everything possible is done to understand what happened and why it happened, and to prevent it from ever happening again. These crises have the power to be used to transform the organization to a dramatically better one. The individuals and organizations referenced in Acknowledgements, Appendix D, and the references in this white paper help to show us the way. This is the values-based “true north” of respectful management of serious clinical adverse events—the response that leaders would want for themselves and those they love. Health care leaders owe their patients, family members, staff, and community nothing less.

 


In the BMJ Quality & Safety Study (2009), researchers studied why clinicians are often considered “second victims” in the wake of medical errors. The researchers delved into how healthcare providers recover from the guilt and stress involved medical errors, and discuss the elements related to recovery and delineate from the second victim phenomenon. These factors include moving forward, receiving emotional support, and reestablishing a sense of integrity. Researchers recommended that it is important to for healthcare institutions to implement support systems that not only offer emotional aid but also decrease the likelihood of future adverse events.

 

 

 


Researchers acknowledged how a majority of adverse medical events involve patient harm. Patients and family are known as first victims. Researchers also acknowledged how healthcare professionals are also considered victims after an adverse event, due to the emotional and psychological trauma experienced after it. In other words, healthcare professionals are also known as second victims. In this study, researchers analyzed the various coping strategies that clinicians use in the wake of adverse events. These strategies include attending programs that offer emotional aid second victims, as well as taking accountability for the situation and learning from it.

 


Book/Report
Reference to book or report
The field guide to understanding ‘human error’

In The Field Guide to Understanding ‘Human Error,’ Sidney Dekker discusses how organizations can successfully deal with perceived “human error” without implementing new rules, punishing people, or requesting compliance. Dekker discusses how people embody “the Bad Apple Theory,” which states that an institution would be safe and reliable albeit a few irresponsible individuals in it. To combat this theory and “human error,” Dekker encourages organizations to learn to understand mistakes, how to improve investigative processes, and how to increase the safety climate of the workplace. He does this by offering specific strategies that encourage organizations and employees to think creatively to foster a safe environment that mitigates “human error.”

 


Video
CRP related video, movie
The Lewis Blackman Story – YouTube Video

This YouTube video recounts the true story of Lewis Blackman, a 15-year-old boy who died in a hospital following routine surgery. This story sheds light on the importance of healthcare providers to not only be cognizant of their patients’ conditions,  but to also frequently engage with families so they feel involved in patient care.

This story has been taken from the Book “Wall of Silence” authored by Rosemary Gibson and Janardan Prasad Singh. The story can be found in Part One “Breaking the Silence”-“The Human Face of Medical Mistakes” page no-31.


Journal Article
Published articles related to CRP
The Science of Human Factors: Separating Fact from Fiction

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

Read more here.


Journal Article
Published articles related to CRP
The Second Victim of Adverse Health Care Events, Nursing Clinics

This article discusses on how healthcare professionals are often considered “second victims” of adverse medical events, due to the psychological and emotional trauma they experience. To support second victims, it is important for health institutions to implement early warning systems that address harm risks associated with adverse incidents. In this article, researchers specifically focus on nurses and how respond to adverse medical events.

 


Journal Article
Published articles related to CRP
The Sorry Works! Coalition making the case for full disclosure.

This thesis paper delves into the importance of classifying healthcare conflicts into relationship-based groups  to appropriately address the dynamics, goals, and interventions associated with the conflict. These dynamics include ways of improving communication and rapports, as well as efficiently saving money.

 


The Medstar’s Patient Safety and Quality Program included this video in their patient safety and care program. This video illustrates the story of Michael Skolnik, who lost his life due to medical malpractice. The error involved the surgeon not being completely transparent with the patient or his family about the surgical procedure. This video emphasizes the importance of shared decision making between patients, families, and physicians to avoid future adverse medical outcomes, especially ones in which lives are lost.

 

 


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
TJC Framework for Conducting a Root Cause Analysis and Action Plan

The Joint Commission’s Framework for Root Cause Analysis (RCA) and Action Plan offers a holistic outline of questions used for healthcare organizations to analyze adverse events in the workplace. Questions include identifying specific protocols in the procedure, external factors, staffing numbers, and other factors that could have potentially influenced the adverse outcome.

 

 

 


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
TJC Patient Safety Systems Chapter, Sentinel Event Policy and RCA2

The Joint Commission published three reports that address patient care and reducing risks of adverse health outcomes: the Patient Safety Systems , Sentinel Event Policy, and RCA2. The Patient Safety Systems report explains how healthcare professionals can develop effective measures to promote patient safety and compassion towards coworkers. The Sentinel Event Policy report details how the Joint Commission collaborates with healthcare institutions to promote patient safety and improve systems that reduce the risk of adverse incidents. The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm report illustrates strategies that institutions or individuals can utilize to analyze the hazards and faults in their systems to they can effectively prevent future adverse medical outcomes.

 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
VA National Center for Patient Safety

The goal of the VA National Center for Patient Safety (NCPS) is to offer tool kits, resources, and event analysis methods to help promote patient safety. The NCPS program is based on a systems approach to problem solving that focuses on prevention, not punishment. The organization uses human factors engineering methods and applies concepts from high-reliability organizations, such as aviation, to target and eliminate system vulnerabilities.

 

 


The objective of this study is to analyze incident reports from hospital patients to identify adverse medical incidents and near-miss mishaps in their care. Researchers found that most of the adverse events involving patients are not identified. Thus, it is important for hospital systems to partner with patients to efficiently and quickly identify adverse medical events and errors to promote overall healthcare quality and patient safety.

 


Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
When It Comes to Liability and Patient Safety What’s Good for Hospitals Can Be Good for Patient

Michelle Mello, the Director of the Program in Law and Public Health at the Harvard School of Public Health, analyzed the effectiveness of communication-and-resolution programs (CRPs) in this article. She found that these models are efficient at addressing healthcare liability issues revolving around adverse medical outcomes. These programs offer a guide for healthcare professionals on how to disclose medical errors to their patients, while also developing ways to prevent future adverse events.