Learning From an Adverse Event
In organizations as complex as BWH, the possibility for adverse outcomes exist. When adverse events are reported, the risk manager coordinates a root cause analysis or detailed review of the case to identify where current systems fail in providing the safest possible care.
During a root cause analysis, care providers review the event, providing insight into the multiple factors that contributed to the error. Once the issues are identified, the group develops action items to reduce the likelihood that the error will reoccur. The analysis and associated recommendations are sent to the appropriate vice president for action. Then the Patient Safety Team assists the vice presidents and their managers with follow-up. The adverse events and follow-up recommendations are reviewed at the Care Improvement Council in order for senior executives to hear about improvements as they unfold.
Many adverse events have common threads, such as breaks in communication or flawed processes. Understanding these issues and resolutions can benefit all
caregivers.
Following an adverse event involving similiar-looking IV bags, the leadership took the following risk-reduction steps:
- Changed the manufacturer of Hespan so that the products no longer look alike;
- Created a hemorrhage cart that includes all of the appropriate fluid and blood pressure resuscitation medications for emergencies;
- Made Hespan readily available on the OR carts;
- Provided orientation to new resident staff; and
- Replaced the opaque pressure bags with clear bags over time.
For example, a multi-disciplinary group did a root cause analysis of one event and found IV bags containing Hespan and Heparin flushes, which looked very similar. In addition, the IV bags are put into a pressure bag for rapid administration, and these pressure bags cover the IV bag labels, making a visual check difficult. It was noted that Hespan is kept in the Suremed and Heparin flush is stocked on storage carts in the OR. While the patient fully recovered, the emergent nature of the case heightened the stress and anxiety of the staff and contributed to the inadvertent administration.
For questions or concerns about patient safety, e-mail Tejal Gandhi, MD, patient safety director, Janet Barnes, RN, JD, director of Risk Management, or Erin Graydon-Baker, Patient Safety manager.