● The Annual Report : includes all adverse incidents (per statutory definition) that occur in the course of a calendar year. These reports are due after the first of each year for the previous year. ● Code 15 Report : reports in detail on each serious patient injury, the facility’s investigation of the injury, and whether the factors causing or resulting in the adverse incident represent a potential risk to other patients. The findings of this investigation must be reported to AHCA within 15 days of the adverse incident (Florida Statutes, 2021; State of Florida AHCA, n.d.). Communicating to patients and families In addition to a thorough examination of the medical error with the clinical team, patients have a right to be informed about a medical error. (Gordon, 2005). One of the characteristics of a culture of safety is the emphasis on full disclosure to patients after a medical error has occurred. Although this remains difficult, experts have stressed the need to apologize to patients and their families for errors (Westrick & Jacob, 2016). Full disclosure involves telling the patient and family what went wrong and explaining what will be done to prevent future errors (Westrick & Jacob, 2016). Improvement organizations, like IHI and Leapfrog, have included wording about disclosing errors to patients in their practice standards or guidelines. Error disclosure is required by regulatory, licensing, and/ or government agencies. Likewise, section 395.1051 of the Florida Statutes says, “an appropriately trained person designated by each licensed facility shall inform each patient or an individual pursuant to s. 765.401(1), in person of any adverse incident that results in serious harm to the patient” (Florida Statutes, 2023, para. 1). Equally, the literature supports the inclusion of an apology when disclosing errors to patients (Westrick & Jacob, 2016). Although participation of the patient is key in managing their care, it is important to remember that the responsibility to provide safe care rests with providers and healthcare organizations. investigation. The members of this team should be trained in the techniques and goals of RCA. Multiple investigators allow triangulation or corroboration of major findings and increase the validity of the final results. Based on the concepts of active and latent error, accident analysis is generally broken down into two steps—data collection and data analysis. Data collection is the establishment of what happened through interviews with the relevant parties, document review, and/or field observation. This data is used to generate a sequence or timeline of events encompassing the entirety of the event in question. Data analysis refers to the repetitive process of examining the sequence of events generated with the goals of determining the common underlying factors. These underlying factors establish how the event happened and exactly what part of the sequence failed. Principles of RCA ● Improving performance measures the root cause in a more effective manner than merely treating the symptoms of a problem. ● To be effective, RCA must be performed systematically with conclusions and causes backed up by documented evidence. ● There is usually more than one potential root cause for any given problem.
(d) Was a procedure to remove unplanned foreign objects remaining from a surgical procedure (Florida Legislature, 2021). The risk-management reporting system must include the following: (a) The investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents to patients. (b) The development of appropriate measures to minimize the risk of adverse incidents to patients. (c) The analysis of patient grievances that relate to patient care and the quality of medical services. (d) A system for informing a patient or an individual identified pursuant to section 765.401(1) that the patient was the subject of an adverse incident, as defined in subsection (5). Such notice shall be given by an appropriately trained person designated by the licensed facility as soon as practicable to allow the patient an opportunity to minimize damage or injury. (e) The development and implementation of an incident reporting system based upon the affirmative duty of all healthcare providers and all agents and employees of the licensed healthcare facility to report adverse incidents to the risk manager, or to his or her designee, within three business days after their occurrence. (Florida Statutes, 2021) In addition to reporting internally any adverse incidents and malpractice actions, hospitals and ambulatory surgical centers in the state of Florida must also report to AHCA any injuries of which they are aware that occurred through any healthcare service in their organizations, including events that occurred to patients while they were patients in nursing homes, home health organizations, physician offices, dental offices, or any other source of healthcare service. Florida Statutes sections 429.23, 400.147, and 641.55 require similar reporting of patient injury incidents at assisted living facilities (Florida Statutes, 2022), nursing homes (Florida Statutes, 2018) and health care service programs (Florida Statutes, 2019), respectively. Patient injury incidents are reported through two different types of reports: Root cause analysis process Root cause analysis (RCA) is widely applied to investigate major industrial accidents (Rodziewicz et al., 2023). RCA is a class of problem-solving methods aimed at identifying the root causes of problems or events. RCA has its foundations in industrial psychology and human factors engineering. Many experts have championed it for the investigation of sentinel events in medicine. In 1997, the Joint Commission (TJC) mandated the use of RCA in the investigation of specific individual events in accredited hospitals. RCA is a reactive method of problem detection and solving. This means that the analysis is done after an event has occurred. RCA is also considered a proactive method of error prevention because it is able to forecast the possibility of an event even before that event can occur (Singh et al., 2023). RCA provides a structured and process focused frame of reference to approach a specific individual event analysis. RCA is not a means to cast individual blame in a pervasive or counterproductive manner. The systematic application of RCA may uncover common root causes that link an otherwise fragmented collection of accidents. The analysis process may also suggest system changes which would be designed to prevent future incidents or adverse events. RCA requires rigorous application of established qualitative techniques to produce valid results. Once a specific individual event has been identified for analysis, an interdisciplinary team is assembled to direct the
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Book Code: MFL1227
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