| Analysis of medical errors and adverse events creates opportunities to improve healthcare systems. True or false? | View Page |
| Root Causes are specific, underlying, and identifiable reasons that ________ occur. | View Page |
| These statements define terms related to medical error prevention. | View Page |
| Root Cause Analysis considers potential improvement processes to reduce the likelihood of repeating an adverse event. True or false? | View Page |
| Which statement describes an Adverse Event? | View Page |
| Which item is a product of Failure Mode and Effect Analysis? | View Page |
| RCA Value A technologist performs a venipuncture for glucose testing on the wrong patient. This medical error leads to the patient receiving an incorrect dose of insulin and the patient goes into a coma--this medical error led to an adverse event.
Analysis without RCA:
Determines the technologist should have checked the patient's wristband (the immediate reaction).Questions why the technologist did not also verbally identify the patient (the subsequent reaction).Restates these reactions (in the internal follow-up review).Misses causes discoverable by a detailed and open investigation.
Analysis with RCA:
Includes descriptions of events leading up to a "wrong person procedure" in its reports.Describes 17 separate errors identified in the follow-up investigation.Recommends actions that should avoid reoccurrence of the error. | View Page |
| RCA Considerations RCA considers the following elements:
Factors associated with an adverse eventStudy of specific processes related to the eventPotential improvement processes to reduce the likelihood repeating the eventQuestioning that probes deeply by repeatedly asking "Why?"Analysis that is thorough and credible
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| Sentinel Events JCAHO calls adverse events Sentinel Events. It defines a Sentinel Event as an unexpected occurrence that involves death or serious physical or psychological injury, or the risk that these might occur. RCA analyzes Sentinel Events. | View Page |
| JCAHO and Sentinel Events JCAHO learns about 80% of known Sentinel Events through healthcare organization reports and 20% through information from other sources, such as the media.
In 1996, JCAHO implemented a Sentinel Events Policy for healthcare organizations. This policy requires organizations to monitor and report adverse events, explore their causes, and report on changes they make in response. | View Page |
| JCAHO Sentinel Event ALERTS
Since 1998, JCAHO has issued 25 Sentinel Event ALERTS to the healthcare community. These publications include more than 50 evidence or expert-based recommendations for preventing adverse events.
Sentinel Event Alerts address various error reduction topics:
Transfusion reactionsInpatient suicideInfant abductionsWrong site surgery or other proceduresPatient falls
Laboratory professionals can be involved in all of these types of Sentinel Events.
JCAHO's first Sentinel Event ALERT addressed the common practice of storing concentrated potassium chloride solutions in hospital nursing units.
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| Sentinel Events Review | View Page |
| Analyzing Medical Events You can use your understanding of medical errors, adverse events, and near misses to examine medical situations that have unexpected, negative outcomes.
You analyze these situations by asking several questions: What happened before, during, and after the situation?Who and what factors and circumstances are involved?Were established standard practices followed?Did a medical error or errors lead to this situation? | View Page |
| Root Cause Analysis JCAHO has a very important role in cause analysis of medical errors. Since 1995, it has been increasing its focus on patient safety by requiring in-depth analysis, Root Cause Analysis, to determine the underlying causes of every adverse event.
Root causes are specific reasons that contribute to medical errors. They cause mistakes that lead to great patient harm (adverse events). Usually they can be identified.
Examples:
Using a wrong calculation factor
Neglecting to use directions for complicated tests
Reporting the wrong test result
Using outdated reagents
Testing clotted or partially-filled samplesDiluting a test sample incorrectly
In most cases, management has the authority and means to resolve root causes. Root Cause Analysis also recommends actions to prevent reoccurrence of an adverse event. | View Page |
| RCA Steps
Steps in Root Cause Analysis | View Page |
| RCA Reports RCA reports avoid declaring that errors are caused by preconceived notions or the first mistakes identified.
By definition, RCA emphasizes analysis of situations. Its most important products are detailed reports that describe the sequence of events that lead to adverse events. | View Page |
| Discussion Laboratory discussion meetings help to prevent medical errors. The staff can meet periodically to discuss recent averted adverse events and ones that might have been averted.Discussion should not be about blame. Privacy must be protected, so real names should not be identified. Management can provide guidelines for discussion and analysis.A suggested format for discussion:1. Briefly describe each adverse event.2. Identify its possible causes.3. Discuss relevant guidelines.4. Suggest possible preventive actions.Discussion can include actions that do and do not work to prevent medical errors. | View Page |
| American Society for Clinical Laboratory ScienceThe American Society for Clinical Laboratory Science, ASCLS, joins the leadership effort to prevent medical errors and increase patient safety. | View Page |
| Near Misses Near misses are also related to medical errors: Near misses are medical events that avert unwanted consequences.Someone or something identifies and corrects harmful influences before they cause adverse events.The medical community sometimes calls near misses “close calls.”
For example, a transfusion is stopped when the nurse discovers that the identification number on a unit of blood does not match the unit number on the requisition. This is a near miss for the patient receiving a transfusion of incompatible blood.
Near misses often provide important insight into new ways of preventing medical errors. In this case, a flaw in Blood Bank cross-checking systems is discovered so it can be prevented from causing a medical error. | View Page |
| Medical Negligence Unfortunately, adverse events do occur in healthcare situations. They may or may not be preventable and they may or may not involve medical negligence.
Medical negligence is a legal term. It describes adverse events involving patient care that fails to meet specific, established standards.
Medical negligence occurs when a medical professional does or does not perform the correct action, resulting in great patient harm (an adverse event). | View Page |
| Adverse Events Medical errors lead to adverse events--unintended injuries or other negative health consequences. These unfortunate events are caused by medical mismanagement, not underlying patient diseases or conditions.
Adverse events may or may not be preventable.
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| Preventable and Unpreventable Adverse Events Adverse events due to medical errors are usually preventable. Adverse events due to uncontrollable factors are typically not preventable. | View Page |
| Bleeding After a Venipuncture Can Be an Adverse Event Excessive bleeding after a venipuncture can occur as a preventable or an unpreventable adverse event. Laboratory professionals might or might not have control over this situation because of the factors involved. For example:
Bleeding due to failure to apply immediately pressure on the venipuncture site is a preventable adverse event. Bleeding due to later injury to the venipuncture site is an unpreventable event. Circumstances that cause the bleeding determine whether it is a preventable or unpreventable adverse event. | View Page |