Blog Five- Chapters 8 & 9

Why Incident Investigations Fail to Improve Patient Safety

The article I selected this week discussed the importance of root-cause analysis for improving patient care. It is recommended that organizations should not look at the next quality improvement issue until the one they are working on is complete. Hospitals have been performing root-cause analysis for more than 10 years, but they continue to experience repeat incident. This is probably due to the fact that the original incident was not properly addressed.

Many people today think that we should stop using root-cause analysis and find a method that guarantees success. I think instead of finding a different method, hospitals should take the responsibility of addressing the original problems that limit the importance of incident investigations. This article made several recommendations that should help improve the outcomes of performing root-cause analysis. They include:

* Find and resolve latent conditions as well as root cause

* Treat the cause rather than try to change people

* Get rid of the “Oh wells”

One example in the article, mentioned the 2003 Columbia Space Shuttle disaster and how the investigation did not end at root-cause analysis. The investigators continued to ask “Why”, which lead to the underlying reason for the disaster being exposed. I think it is sad that the reason for this tragedy was due to schedule pressures; and, the staff at NASA disregarded concerns and continued with the launch. In this situation, root-cause analysis would be a valuable tool to help prevent this from occurring in the future.

Another interesting point in the article was to perform process redesign instead of changing people’s behavior through interventions such as retraining or memory aids. It is human nature to blame someone else for your mistake, but it is about time that people in the healthcare field start owning up to their mistakes. If someone realizes the potential for harm they should work to redesign the process so that the possible incident will not occur again. It is our responsibility to speak up in order to protect patients. The article suggested using rapid-cycle PDSA, which stands for Plan, Do, Study, Act. I had never heard of this process, but it is used to perform tests on process redesign to allow the organization to respond immediately if safety interventions do not work out.

As I stated before, I think the solution is not to find a new technique for improving quality and safety, but make the current approach more successful.

Quality Tool- VA National Center for Patient Safety: Root- Cause Analysis

Root-Cause Analysis a tool used to identify prevention strategies in order to build a safe environment and move beyond the culture of blame. This quality tool identified several goals of root-cause analysis. To discover:

* What happened?

* Why did it happen?

* What to do to prevent it from happening again

I am not going to go into the steps of root-cause analysis because we have already studied this in Ms. Morey’s class. However, I am going to point out some tips to be more thorough when performing root-cause analysis. To be thorough, a root-cause analysis must include:

* Determination of human and other factors

* Determination of related processes and systems

* Identifications of risks and their potential contributions

* Determination of potential improvement opportunities in processes or systems

It is easy to forget about quality when you are performing the same tasks daily. That is why this tool is used to discover hidden faults in a process to enable us to correct them. I thought it was interesting that in order for a root-cause to be credible, it should be internally consistent and include consideration of relevant literature. It is also helpful to have the participation of upper management. It is important that they know what is going on in their facility, both good and bad.

http://www.patientsafety.gov/rca.html

Classmate Pick of the Week- Ramona’s Blog

This week I read Ramona’s blog discussing the opportunities for improvement. I agree with her regarding the doctor’s office at being the primary source of healthcare. In today’s society, it is hard for people with insurance to pay for medical bills, so imagine the stress and burden the uninsured experience. Before I came to UMMC, I was one of those that was stressed and burdened by the astronomical cost for healthcare. There should be improvements made to enable to same quality of healthcare at a reasonable cost. Ramona’s point about the patient feeling they got a “raw deal” is true. Often, patients leave their PCP without answers.

Blog 4

Facts about the Unannounced Survey Process

The article I read this week was from The Joint Commission website was entitled Facts about the Unannounced Survey Process. As we all know, The Joint Commission is infamous for their unannounced surveys. There are several reasons why they might pop-in on your organization such as to help you focus on providing safe, high quality care and to affirm the expectation of continuous compliance.

An organization that is scheduled for a survey is usually given 18-39 months notice. To me this seems like enough time to get your ducks in a row, unless your organization has a 60% delinquency rate. One thing that surprised me was that JCAHO posts the biographies and pictures of the surveyors assigned to your facility on their website the morning of your survey. This would be useful because the key employees targeted for the survey could better recognize the surveyor and not be caught off guard.

Another thing pointed out were the few exceptions to unannounced surveys. I know that all organizations wished they fit into one of the following categories: initial survey, first surveys for organization that choose the Early Survey Policy option, or Periodic Performance Review Option 2 and Option 3 surveys. This would allow the organization to better prepare because they would know farther in advance the survey was approaching. However, all hospital and CMS deeming or recognition surveys are unannounced.

I also thought that allowing organizations the ability to identify up to 10 days in which unannounced surveys should be avoided was a positive component of the survey process. Despite the privilege to identify these days, JCAHO has the right to conduct the survey during an “avoid day”. I enjoyed this article because it shed some light on some aspects surrounding JCAHO’s survey process.

http://www.jointcommission.org/AccreditationPrograms/unannounced.htm?print=yes

20 Tips to Help Prevent Medical Errors in Children

The quality tool I selected this week discussed medical errors in children. This caught my eye because my nephew and both nieces have been sick lately. We have all heard of the IOM’s report, To Err is Human, which pointed out that an upwards of 100,000 unnecessary medical errors occur each year. This number, however, was in 1999; so imagine the figures today. The goal of this tool was to point out that most medical errors result from problems created in today’s complex health system, and to equip parents’ with the necessary tools to help prevent them. If you are interested in learning more about the 20 tips to preventing medical errors in children, please click on the link below.

http://www.ahrq.gov/consumer/20tipkid.htm

Classmate Pick of the Week

This week I reviewed Tammi’s blog about what to do when getting a prescription. I agree that it is important to be involved in your healthcare. As HIM professionals, we should be advocating for PHRs and encouraging others to take charge of their health. I also agree that it is important to relay any medications you are taking. A provider needs to know this information so he/she does not prescribe something that could potentially interact with your current medications. I recently visited my PCP and his nurse did not ask if I was currently taking any medications. He was upset when he discovered she was not documenting this information. Therefore, it is your responsibility, as the patient, to provide this information even when you’re not asked. Another point Tammi made was to always check your prescriptions at the pharmacy. My sister experienced getting a prescription for her daughter with no dosage on it. This caused her have to call the pharmacy and request this information. If she would have checked the prescriptions before she left, she would not have had to call.