○ How can the same outcome be avoided next time? ○ What is the follow-up action plan? In addition to participating in safety briefings, mental health professionals can contribute to the culture of safety in their organizations by committing to a personal practice of being mindful of the language they use, for example, asking “What happened?” rather than “Who did it?” when something goes wrong. The importance of culture cannot be overemphasized (Montague et al., 2019). In the years since the publication of the IOM report, there have been countless initiatives to develop and implement safe practices and to train healthcare workers in patient safety at the local, national, and international levels. Despite these efforts, healthcare organizations are still striving to improve safety and will continue to do so until the culture is transformed. ● Analyze underlying cause-and-effect systems through a series of “why” questions to determine where redesign of a work process might reduce risk ● Identify risks and their potential contributions to the adverse event or close call ● Determine improvements in processes and systems that might decrease the likelihood of such events in the future, or after analysis, determine that no such improvement opportunities exist ● Include participation by the organization’s leadership as well as those involved in the processes and systems under review ● Be internally consistent (i.e., be conducted the same way every time, not contradict itself or leave obvious questions unanswered) ● Be informed by relevant literature and research ● Include corrective outcome measures and top management approval Self-Assessment Question 2 The director of patient safety for a group of more than 50 inpatient psychiatric hospitals, each facility serving varying populations, geriatric, adults, adolescents, and children, hires a consulting firm to propose a company-wide new process involving an RCA of adverse events. How might this approach be ineffective? a. Failure to learn specific circumstances at each hospital could make the effort too generic. b. The program might be too expensive, disrupting hospital budgets. c. Staff may be too busy to attend training and study new process manuals. d. If the training occurs near the holidays, staff may be on vacation. major depressive disorder, places him on periodic suicide watch, and promises to return that evening to complete his assessment. To eliminate any possibility of miscommunication, Lee, the interpreter, explains all of this to both Mr. Chey and his daughter. In response, Mr. Chey asks one question: Will he be allowed to pray in his room? Lee answers yes, and then receives a call that he is needed in another part of the hospital. On his way, Lee places a call to Amy, the social worker, and leaves a voicemail message, asking that she call him about Mr. Chey and requesting that she convene a family session the day after tomorrow, which is when he is next scheduled to work at the hospital. Jenn, a nurse, and Elise, a nursing assistant, are working the evening shift. They agree to share responsibility for monitoring Mr. Chey’s suicide watch and decide to check on him at five- minute intervals. With Mr. Chey’s admission, the unit is at full capacity, and he is given the only vacant room, at the far end of the corridor. Each time Jenn or Elise pass his open door, they
When an adverse event does occur, everyone involved in direct care should attend the safety briefing to fully understand what happened and to brainstorm ideas about how to integrate the learning into future actions. Notes taken during the briefing are informal and not forwarded to supervisors so that staff members feel free to share knowledge without fear of embarrassment or recrimination. One person is assigned to take responsibility for any needed follow-up. Some of the key features of a safety briefing include the following. ● Involving everyone who provides direct care, led by a senior clinical provider ● Scheduled daily meetings that are brief (15 minutes) ● Asking critical questions: ○ What happened to threaten client safety? ○ What should have happened? ○ What accounted for the difference? Root Cause Analysis Root cause analysis is a structured problem-solving method that was initially developed to analyze industrial accidents. It is designed to look beyond the immediate outcome, that is, active failures that occur at the sharp end (the point of interface between humans and a complex system) to expose blunt end problems (the latent failures hidden within the system) that contribute to adverse events. When a sentinel event occurs, a root cause analysis seeks to identify not only what happened but also why it happened and what can be done to prevent it from happening again. A root cause analysis is the structured process of questioning why a sentinel event occurred; it uncovers information that is then used to develop strategies to prevent another adverse outcome (Oster & Braaten, 2021). Unfortunately, researchers assert that root cause analysis (RCA) programs and their effects on patient safety are not well understood. Studies reveal that RCA has great potential in healthcare settings; however, researchers point out the specific context in each setting and the effort to customize RCA process are key factors for creating value potential (Peerally et al., 2017). Nonetheless, all behavioral health organizations that participate in The Joint Commission’s accreditation program are required to conduct a root cause analysis following a sentinel event (defined by The Joint Commission as any unanticipated event that results in death or serious physical or psychological injury and that is unrelated to the patient’s illness). The following list identifies The Joint Commission’s requirements for a thorough and credible root cause analysis. According to the U.S. Department of Veterans Affairs (2014), an RCA must accomplish the following criteria. ● Identify human factors (such as distraction, communication failure, and fatigue) and processes and systems most directly associated with sentinel events or close calls Case Study 2 The following case demonstrates a root cause analysis that was conducted following a sentinel event, and it meets The Joint Commission’s criteria. Khemrin Chey is a 60-year-old widower who emigrated from Cambodia through a church-sponsored program. A former teacher, Mr. Chey lives with his married daughter and works as a janitor for the church. This afternoon, the pastor discovers Mr. Chey sobbing in the church basement and calls his daughter, who brings her father to the hospital emergency department. Lee, an interpreter who works at the hospital, assists Dr. Gordon, the psychiatric resident, as he evaluates Mr. Chey for admission. Mr. Chey’s daughter provides recent history, reporting that her father has refused to eat for the past two weeks and has slept less than three hours a night during this time. Since his arrival in the U.S., Mr. Chey has repeatedly told his daughter that he desires to join his deceased wife. At this point in the interview, Dr. Gordon is paged to another emergency. He admits Mr. Chey to the psychiatric unit with a provisional diagnosis of
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Book Code: PCUS1624
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