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.
Risk Reduction Strategies
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 manager 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 learn 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. For example, one root cause analysis revealed IV bags containing Hespan and Heparin flush look very similar. The multi-disciplinary group conducting the analysis also found that the IV bags are put into pressure bags for rapid administration, and the 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.
Committed to changing processes to prevent such occurrences in the future, the leadership took the following risk reduction strategies:
- 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 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.