● 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.). 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. 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 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 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.
Self-Assessment Quiz Question #3 A healthcare provider in the State of Florida has appropriately submitted an incident report for a sentinel event that occurred during their shift on May 1. The risk management department at the facility must investigate the incident and submit their findings to the State of Florida by what deadline? a. May 7.
b. May 15. c. May 31. d. June 1.
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. 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. ● To be effective, the analysis must establish all known pieces of the puzzle between the root cause(s) and the actual problem(s). ● Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a focus on variability reduction and risk avoidance. Applying the process of RCA When people discover problems, the most frequent response is to rush to find a solution. Finding an immediate fix to a problem may be very satisfying for the moment but is not a long-term effective decision. The purpose and goal of applying RCA to medical errors that occur or that might occur is to find effective solutions rather than only discovering root causes. Root causes are secondary to the goal of prevention and are only revealed after deciding which solutions to implement. 1. Define the problem . The therapist can ask the following questions: What does the medical facility want to prevent? When and where did it occur? What is the significance of the problem? Is it possible to close the gap between patient safety and the accurate or effective process that defines the problem?
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