Identifying and analyzing medical errors Improving patient safety involves recognition of errors, followed by the analysis of their root causes and contributing factors. Developing and implementing a plan to prevent or control future errors is also necessary to complete the process. Determining the actual rate of medical errors is difficult because most estimates are based on self-report. This requires the reporter to identify that an error has occurred, recognize that it is a reportable event, and not fear repercussions from reporting the event. These “incident” reports represent a small portion of actual medical errors (Jeffery Woo & Avery, 2021). Identification of errors In healthcare, it is widely known that only a small percentage of adverse events and/or near misses are reported. As a result, to improve the measurement of patient safety events in healthcare organizations, AHRQ developed a set of patient safety indicators (PSIs) that can be used with hospital discharge data to screen for potential errors (AHRQ, 2015). The PSI set includes 20 hospital-level indicators and seven area-level indicators. Similarly, in 2004, IHI developed a list of 53 triggers to identify potential adverse events that occurred during hospitalization. Though this tool has been revised, it is still widely used to identify and analyze adverse events (Garrett et al., 2013). Although both of these tools are useful in determining whether a patient has suffered from an adverse event, they do have some limitations. For example, both tools give a retrospective focus, meaning that the event is not identified until after the patient has suffered harm. Also, both require additional review to determine if there was a preventable adverse event. Not all preventable adverse events will be identified. Sentinel event The Joint Commission (TJC) defines a sentinel event as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's Mandates within the State of Florida Regulation Alert for the Florida Healthcare Professional! In the State of Florida, as part of continuing education requirements for licensure renewal, all healthcare professionals must obtain a minimum of at least two (2) hours of approved training on Prevention of Medical Errors. Although reporting sentinel events to TJC is voluntary, Florida law makes reporting of sentinel events mandatory. Florida’s Comprehensive Medical Malpractice Act of 1985 (F.S. 395.0917) mandates that each licensed hospital must implement a risk management program with state oversight and an internal incident-reporting system. Oversight is provided by the State of Florida Agency for Health Care Administration (AHCA). Each licensed hospital is required to hire a risk manager who is responsible for the implementation and management of the risk management program (Florida Statutes, 2021). Florida Statute 395.0197 mandates internal reporting of any adverse incident (event): over which healthcare personnel could exercise control, and which is associated in whole or in part with medical intervention, rather than the condition
illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. It should be noted that not all sentinel events are the result of an error and that not all errors result in a sentinel event (TJC, 2023b). The following sentinel events require the completion of a root cause analysis (RCA), which will be discussed next in this course: ● Suicide that takes place within a facility that is fully staffed around the clock, or suicide that takes place within 72 hours of discharge, including from the hospital’s emergency department. ● Unexpected death of a full-term infant. ● Abduction of a patient. ● Any elopement (unauthorized departure) of a patient from a facility staffed around the clock leading to death, permanent harm, or severe temporary harm. ● An infant being sent home with the wrong family. ● On-site rape, assault, or homicide of a patient, staff member, visitor, or vendor. ● Hemolytic blood transfusion reaction caused by use of the wrong blood group. ● The wrong invasive procedure, or an invasive procedure on the wrong patient or the wrong site. ● A foreign object left inside a patient after a surgical or any invasive procedure. ● Severe neonatal hyperbilirubinemia. ● Too much radiation or radiation to the wrong part of the body. ● Fire, flame, unanticipated smoke, heat, or flashes during direct patient care caused by equipment operated and used by the hospital. ● Any maternal death that occurs during the birth process. ● Severe maternal morbidity (a patient safety event that occurs from the intrapartum period through the immediate postpartum period requiring transfusion of four or more units of packed red blood cells and/or admission to the intensive care unit). (TJC, 2023b) ○ Brain or spinal damage; ○ Permanent disfigurement; ○ Fracture or dislocation of bones or joints; ○ A limitation of neurological, physical, or sensory function which continues after discharge from the facility; ○ Any condition that required specialized medical attention or surgical intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent; or ○ Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patient’s condition prior to the adverse incident; (b) Was the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient’s diagnosis or medical condition; (c) Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk as disclosed to the patient and documented through the informed- consent process; or
for which such intervention occurred, and which: (a) Resulted in one of the following injuries: ○ Death;
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