Learning From Patient Safety Events in Acute Care Hospitals in Ontario

1. Learning From Patient Safety Events in Acute Care Hospitals in Ontario Interactive Dissemination Workshop, November 10th, 2009 g Sheraton Toronto Airport Hotel and Conference Centre f Study Objectives Phase I: Use Focus Groups and Expert Panel to validate typologies of (1) Potential Learning Events (PLEs), and (2) responses to PLEs Phase II: To examine the factors that influence learning from safety failure events in acute care hospitals Welcome Research funded by the Canadian Institutes of Health Research

2. How do providers and managers categorize patient safety events (PSEs)? November 10th, 2009Learning from PSE Study Dissemination Day Liane R. Ginsburg Ginsburg, L.R., Y. Chuang, J. Richardson, P.G. Norton, W. Berta, D. Tregunno, P. Ng. Categorizing Errors and Adverse Events for Learning: The provider perspective. (2009) Healthcare Quarterly, 12:154-160.

3. FG Preamble and questions • Intro to errors and AEs, terminology, etc • Q1. What kinds of events might provide valuable opportunities for learning and reducing similar events in the future? • Recall, events can be differentiated based on: • Whether they are preventable • How serious the outcome is • How often the event occurs • When the event is discovered (e.g. before or after it causes harm) • Where the event occurs • …Other factors

4. Sentinel Events Q2: 5 Categories of PSEs – Are these clear?...any categories problematic? • Near miss • AE causing minimal harm but no prolonged hospitalization • AE that results in prolonged hospitalization but no disability at discharge • AE that results in disability at discharge • AE that results in death

5. FG Findings Categories typically used in incidence studies are not particularly useful for understanding everyday practice: • Difficulty with language • Difficulty with categories – is disability permanent? • Difficult to slot many events • Events could move between categories • Judgments about preventability often not clear to providers

6. FG Findings Wrt kinds of events most valuable for learning, most interesting and most prominent themes • Focus on preventable events • Near Misses complex (promixity to pt. and harm potential) • Severity of harm key for distinguishing events

7. NB_FL: The worst thing is, the closer you are to the patient [when you catch an NM] .. you know obviously you're gonna learn very quickly. • NB_FL: (17:34) get yourself on the first step .. whatever, however many ever steps we're talking about .. I think the first step .. when you're standing at .. the drug cart .. and you've made an error and you've caught it. That's a minor incident, nothing happened. You know you're gonna say .. you're going to be careful next time whatever. But as soon as you take that needle and you're just ready to give .. I think at that point it becomes major. (also reflects 2.5) • Divide NMs and events are major or minor

8. Near Misses have the potential to cause varying degrees of harm from none to very serious (near misses can be caught far from to very close to the patient) Grey areas representing events between categories Arrows reflect increasing severity of the events (red) and near misses (green) Typology of Patient Safety Events Minor Event Major Event Moderate Event Minor Near Miss Events can cause varying degrees of harm from none to very severe Major Near Miss Definition: An event that would have resulted in no harm or very minimal temporary harm to the patient but did not because it was caught or because of good luck. Examples: Noticing that you have dispensed extra-strength Tylenol when Tylenol 2 was ordered Definition: An event involving no harm or very minimal temporary harm to the patient. Examples: Administering Extra-strength Tylenol instead of Tylenol 2’s; a missed suppository and patient suffers one day of mild constipation; staff forgets patient’s appointment for seating servicing and a patient must wait another week for a new chair Definition: An event that causes discomfort sufficient to interfere with usual activity and requires additional specific therapeutic intervention but, poses no significant or permanent risk of harm to the patient. Examples: Post stroke patient on dysphagic diet is given thin fluids and aspirates resulting in pneumonia, resolves with treatment Definition: An event that would have resulted in death or serious physical or psychological injury but did not because it was caught or because of good luck. Examples: Interrupted attempted suicide by hanging, wrong patient is sent for a surgical procedure and is discovered in the OR Definition: An event involving death or serious physical/psychological injury. These events should not be considered ‘stuff’ that ‘just happens’. Nor should they be considered inevitable. Examples: Unanticipated death or major permanent loss of function; suicide; hemolytic transfusion reaction involving administration of blood; surgery on the wrong patient or wrong body part.

9. Understanding what kind of events are relevant to staff and managers in daily practice Methods • 10 FGs conducted in acute care hospitals (large and small) with clinical care mangers, RNs and pharmacists • Recorded, transcribed and analyzed using NVivo • A typology of PSEs that includes 4 categories, definitions, and examples was developed from the focus group data • The typology was validated through a follow-up mail questionnaire to all 74 focus group participants (response rate 65%)

10. How helpful are the 4 types of PSEs for understanding practice? N=48 (focus group participants)

11. Application • PSE types: • emerged from those at the front-lines • are seen as meaningful for practice • Important subsequent learning piece built on event types meaningful to those in practice • Useful for practice • Questions?

12. To what extent does your organization engage in learning responses following:  Major events Minor events