MedXellence Medical Incident Analysis: Group Exercise Guidance Materials for the Patient Safety Video Presentation In this exercise you will observe a clinical/administrative sequence of events that that trace the progression of a patient from their initial encounter through their course and outcome. Unlike the circumstance of evaluating and analyzing an event after it has occurred, you will not know the outcome(s) until the final scene is complete. In this circumstance you will not be subject to hindsight bias. This is the very human tendency to pass judgment on the people and the events leading up to an accident when the outcome is known. Essentially this confers our perception of reality onto the events and individuals we are evaluating. This educational activity is designed to duplicate the patient physician clinical reasoning experience when one starts with the initial information, decisions are made, and the subsequent course of events and their outcomes are determined by the natural history of the underlying disease and the interventions related to the health care delivery system. To make the most of this interactive case-based exercise you are provided with the following number of the most salient topics included here as definitions, comments, and principals. An adverse outcome is an occurrence or condition associated with healthcare activities or health services when they cause unexpected harm to a patient during the provisions of such care or services. These may be because of acts of commission or omission. Identifying something, as an adverse event does not imply "error," "negligence," or poor quality care. It simply indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. An adverse event attributed to error is considered a preventable adverse event. Preventability: Implies that methods or information for averting a given action/outcome are known and that an adverse event results from failures to apply that knowledge. Error is a failure of a planned action to be completed as intended (error of commission), a failure to take an appropriate action (error of omission), or the use of a wrong approach to achieve an aim (error of planning) that leads to an undesirable and unintended outcome. Knowledge Based Mistakes: Mistakes reflect failures during attentional behaviors behavior that requires conscious thought, analysis, and planning, as in active problem solving. Rather than lapses in concentration (as with slips), mistakes typically involve insufficient knowledge, failure to correctly interpret available information, or application of the wrong cognitive heuristic or rule. Thus, choosing the wrong diagnostic test or ordering a suboptimal medication for a given condition represents a mistake. Usually reflect lack of experience, insufficient knowledge, failure to correctly interpret available information, or deficits in training. Hindsight Bias: In a very general sense, hindsight bias relates to the common expression "hindsight is 20/20."This expression captures the tendency for people to regard past events as
expected or obvious, even when, in real time, the events perplexed those involved. After learning the outcome of a series of events, people tend to exaggerate the extent to which they had foreseen the likelihood of its occurrence. In the context of safety analysis, hindsight bias refers to the tendency to judge the events leading up to an accident as errors because the bad outcome is known. The more severe the outcome, the more likely that decisions leading up to this outcome will be judged as errors. Judging the antecedent decisions as errors implies that the outcome was preventable. In legal circles, one might use the phrase "but for," as in "but for these errors in judgment, this terrible outcome would not have occurred." Those reviewing events after the fact see the outcome as more foreseeable and therefore more preventable than they would have appreciated in real-time. Slips and Lapses: Skill Based Performance: Slips refer to failures of schematic behaviors, or lapses in concentration (e.g., overlooking a step in a routine task due to a lapse in memory, an experienced surgeon nicking an adjacent organ during an operation due to a momentary lapse in concentration). Slips occur in the face of competing sensory or emotional distractions, fatigue, and stress. Reducing the risk of slips requires attention to the designs of protocols, devices, and work environments using checklists so key steps will not be omitted, reducing fatigue among personnel (or shifting high-risk work away from personnel who have been working extended hours), removing unnecessary variation in the design of key devices, eliminating distractions (e.g., phones) from areas where work requires intense concentration, and other redesign strategies. Slips can be contrasted with mistakes, which are failures that occur in attentional behavior such as active problem solving. Communication Points Communication is the process by which information is transferred between individuals and within social structures and organizations. Communication should be a two-way process of the exchange and progression of thoughts, opinions, or ideas towards a defined goal. Handoff/transition of care communication is a real-time, interactive process of passing patient specific information from one caregiver or team to another for the purpose of ensuring the continuity and safety of the patient s care. (Modified from UVA Health Systems) Handoff of care occurs when responsibility for patient care changes due to a change in patient location or change in provider, this includes the transition of care to the patient themselves for post encounter care. As a basis for the communication level necessary for a safe transition of care, a successful oral case presentation provides the information that is important to allow for the listener to immediately apply clinical reasoning and to sustain this method of clinical thinking in the post presentation period.
Allocation of sufficient time for communicating important information and for participant in the exchange to ask and respond to questions without interruptions is a major requirement. Relevance is a term used to describe how pertinent, connected, or applicable something is to a given matter. A thing is relevant if it serves as a means to a given purpose. Clinical relevance defines all data available about a specific patient. Rhetorical Relevance: the logical framework in which communication trims away excess information to create the concise discourse necessary to make the required point(s). The rhetorical model breaks communication into four essential components: message, audience, purpose, and occasion. Rhetorical relevance defines that which is of interest to a particular audience for a specific patient related issue. Appropriate selection and level of detailed information required to maintain continuity of care and deal with evolving or new events. REAL TIME ANALYSIS OF CLINICAL EVENTS Due to the complex nature of systems, there is routinely no single or root cause for most accidents. We know that single causes are rare, but we don t know how small events can become chained together so that they result in a disastrous outcome. In the absence of this understanding, people must wait until some crisis actually occurs before they can diagnose a problem, rather than be in a position to detect a potential problem before it emerges. To anticipate and forestall disasters into understand regularities in the ways small events can combine to have disproportionately large effects. Karl E. Weick The observable result occurs at the sharp end, the point where the patient interacts with the system. The frontline interface relationship between the organization and its beneficiaries connects the organization s core competencies with the needs of the individual patient. Active Failures Errors that occur at the level of the frontline operator, usually a direct effect on the integrity of the defenses, and their results are felt almost immediately. Latent Conditions Breaches in the system s defenses, barriers, and safeguards whose potential existed for some time prior to the onset of the accident sequence, though usually without obvious bad effect. Usually these decisions and actions occur at a distance from the actual operational activities but may ultimately affect the observed sharp end human performance and behavior as well as significantly shaping the environment in which it occurs.
As you review each segment of the developing case, keep in mind that the quality, safety component, and value for any single patient or cohort of patients is a function of the complexity of the system in which they occur. Each subsequent encounter is affected by the interactions that preceded it. People do not act in isolation, the question to consider is why did a person act in a particular way at a particular moment, what influences were in play at the time, and what are the potential and actual effects of these influences on the individual s final actions. You should consider the behavior of the individuals in your analysis. Behavior is described as the result of the interaction of a person and the environment and is the basis for complex adaptive activities. Look at what the people in this case are experiencing and look at the interactions and activities that are occurring simultaneously. Were there distractions in the environment; was there time to think, what was the status of the individuals with regard to skill level, fatigue, and stress? Was their adequate communication of critical information? What resources are available to them? Where can they go for help when they recognize that the situation is exceeding capabilities and resources? As you observe the various patient-provider-system interactions use items from the provided problem list to set the stage for your differential as to causation/contributing factors of the various outcomes including a diagnosis of a slip vs. a mistake. This approach allows for the development of an intervention(s) to prevent re-occurrence or allow containment (treatment). A brief review of complexity as applies to this exercise: Complex systems contain many agents, but they differ from complicated systems because the agents in complex systems have more autonomy. This autonomy allows the parts to interact in unpredictable ways, behave in a non-linear manner, which in turn causes the system as a whole to behave or manifest itself unpredictably as well. Complex systems show sensitivity to initial conditions and are not the sum of its individual parts. It is the interaction between the parts (agents) that ultimately gives complex systems their form. AGENTS AND INTERACTIONS Individual Behaviors Personality Fear Frustration Anger Stress Fatigue Provider hierarchy Teamwork Language
Communication Clinician/patient-family communication Handoffs (transitions of care) Clinician/support staff communication Physician/Physician Communication Nurse/physician communication Nurse/nurse communication Human Factors The Work Environment Technology Scheduling system EMR Administrative Support Systems Accident prone procedure(s) Workspace organization Distractions Noise Questions to Guide the Event Analysis by Geographical Area of Activity Initial Clinic Visit: Appointment Desk 1. Describe the appointment area working environment. 2. What is the objective of the patient - administrative staff interaction? 3. What are the expectations on the part of the physician? 4. What are the expectations on the part of the family/patient? 5. How were these expectations dealt with? 6. Were the resultant actions successful? Why not? 7. What policy/procedures was the administrative staff following a. How would you determine the administrative staff job descriptions and areas of performance evaluation? OB Triage Area: Intake Desk 1. Describe the triage area working environment. 2. What is the objective of the administrative staff (triage clerk) - patient interaction? 3. What are the expectations on the part of the staff? 4. What are the expectations on the part of the family/patient? 5. How were these expectations dealt with? 6. Were the resultant actions successful? Why not? 7. What policy/procedures was the administrative staff following?
a. What are the administrative staff job descriptions and areas of performance evaluation? b. What is her primary concern? c. What role has she played in the patient s care? 8. Describe a 2 key latent conditions disclosed by this situation. OB Triage: Examination Area 1. Describe the triage area working environment. 2. What are the expectations on the part of the nurse? a. Does she have the clinical data she needs? b. Where is the information available? c. What is the quality of the information? d. What are alternative sources? 3. What is the objective of the nurse - patient interaction? a. Does she understand the patient s primary complaint? b. Does she provide necessary information to the patient? 4. What are the expectations on the part of the patient? a. How were these expectations dealt with? b. Were the resultant actions successful? Why/Why not? Labor and Delivery Holding Area: Nursing Staff 1. Describe the OB holding area working environment. 2. What is the objective of the nurse-nurse transition of care? 3. What are the expectations on the part of the receiving nurse? a. Does she have the clinical data she needs? b. Where is the information available? c. What is the quality of the information? 4. What is the objective of the patient/family - nurse interaction? b. What information is available? c. What information is documented? 5. What are the expectations on the part of the patient/family? a. How were these expectations dealt with? b. Were the resultant actions successful? Why/why not? 6. How is critical clinical information being collected, documented and disseminated to each of the caregivers as they enter the activity? 7. What active and latent factors have contributed to the delay in appropriate diagnosis
Labor and Delivery Holding Area: Nursing Physician Interactions 1. Describe the OB holding area working environment. 2. What is the objective of the physician nurse interaction? 3. What is the relationship between the two? 4. What are the expectations on the part of the physician? a. What information should have been provided to the physician? 5. What are the expectations on the part of the nurse? a. What would have been an alternative approach to speaking with the resident? b. What would have been an alternative response by the nurse to the assignment of the medical student? 6. How were these expectations dealt with? 7. Were the resultant actions successful? Why/Why not? 8. What information should have been conveyed to the patient and her husband prior to the rapid transfer to the OR? Operating Room: Induction and Delivery 1. How did the preceding delays in diagnosis and treatment effect activities in the OR? 2. Describe the operating room working environment. a. How were the roles of the individuals in the OR defined? b. What is the professional hierarchy? i. Does this effect communication? 3. What was the level and objective of communication with the patient? 4. What is the objective of the physician resident physician interaction? b. Was this objective met? 5. What is the objective of the surgeon anesthesiologist interaction? b. Was this objective met? 6. What active error delayed appropriate emergency care? 7. What latent condition delayed appropriate emergency care? 8. What active and latent conditions facilitated the medication error?