APNA 29th Annual Conference Session 4012: October 31, 2015 - - PDF document

APNA 29th Annual Conference Session 4012: October 31, 2015 Kirwan 1

Collaborating with Patients and Families to Advance Patient Safety in Mental Health Settings

Nicole Kirwan RN BScN MN CPMHN(C)

Certified Risk Management Specialist Lean Quality Improvement Blackbelt

• The speaker has no conflicts of interest to disclose

DISCLOSURE

As a result of participating in this session, the participant will be able to: 1. Explain the benefits of working collaboratively with patients and families to analyze patient safety incidents that occur during the course of care, placing patients at risk for injury or harm 2. Cite examples the roles patients and families can play in a patient safety incident analysis 3. List some of the advantages of using a structured incident analysis process to analyze patient safety incidents in health care 4. Identify collaborative approaches to working with patients and families to advance patient safety that could be implemented in their own workplaces

OBJECTIVES

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• St. Michael’s is an academic

health sciences center located in Toronto, Canada

• St. Michael’s aims to provide

comprehensive care for an urban community and advance systems of care for disadvantaged populations

• The Mental Health and

Addictions Service provides a full range of hospital and community-based services for individuals living with mental health and/or substance use issues

• ST. MICHAEL’S

Photo: Katherine Cooper St. Michael’s

• St. Michael’s envisions a health system where patients, families,

providers, administrators and governments work closely together to improve the quality of care and make care safer

• Patient and Family Councils have been established in all programs

to optimize patient, organizational and system outcomes

• Collaboration with patients and families in patient safety incident

analysis is a strategic priority for the organization

COLLABORATION WITH PATIENTS & FAMILIES

• St. Michael’s utilizes a

structured patient safety incident management approach to conduct the immediate and ongoing activities following all patient safety incidents that could have resulted, or did result in unnecessary harm to a patient

PATIENT SAFETY INCIDENT MANAGEMENT

PATIENT SAFETY INCIDENT REACHED PATIENT HARM INCIDENT NO HARM INCIDENT DID NOT REACH PATIENT NEAR MISS

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• All patient safety incidents that occur in the organization are

analyzed by local teams of patients, families and clinicians using a structured incident analysis process (Canadian Patient Safety Institute, 2012) that aims to identify: – What happened? – How did it happen? – Why did it happen? – What can be done to reduce the risk of recurrence and make care safer? – What was learned?

PATIENT SAFETY INCIDENT ANALYSIS

• The Mental Health and

Addictions Patient Safety Incident Analysis Team was established in 2010

• The team is comprised of 20

members

– 10 patient or family members – 10 mental health and/or addictions clinicians

• A Clinical Nurse Specialist

and an individual with lived experience co-chair the committee

MENTAL HEALTH & ADDICTIONS TEAM

1 CNS 5 FAMILY MEMBERS 2 SOCIAL WORKERS 1 PHARMACIST 2 REGISTERED NURSES 2 OCCUPATIONAL THERAPISTS 2 PSYCHIATRISTS 5 MPATIENTS

• The team is tasked with analyzing all patient safety incidents that can
• ccur to patients during the course of crisis, inpatient, ambulatory

and community mental health and/or addictions care

• Incident analyses generally focus on nine key patient safety issues

that place patients at risk of harm or injury

– Violence and aggression – Absconding and missing patients – Adverse medication events – Patient victimization – Falls and other patient accidents – Adverse diagnostic events – Suicide and self-harm – Seclusion and restraint – Adverse Events associated with drugs of abuse

MENTAL HEALTH & ADDICTIONS TEAM

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• Recruitment notices for the Mental Health and Addictions Patient

Safety Incident Analysis Team are circulated by the Mental Health and Addictions Patient and Family Council

• Interested patients and families take part in a structured interview to

assess their knowledge of, and interest in patient safety issues

RECRUITMENT OF PATIENTS & FAMILIES

• Patients and family members who have been selected to become

members of the Mental Health and Addictions Patient Safety Incident Analysis Team participate in a two day patient safety incident analysis training program

• Individuals sign confidentiality agreements prior to joining the

team

ONBOARDING OF PATIENTS & FAMILIES

• The Mental Health and Addictions Patient Safety Incident Analysis

Team meets weekly for 2 hours

• Patient safety incident reports are reviewed by the team in order to

select the most appropriate analysis method

– Concise – Comprehensive – Multi-incident

• A mini team of 3 individuals is identified to conduct each patient

safety incident analysis from the larger team

INCIDENT ANALYSIS APPROACH

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• The mini-team meets within one week to gather information

relevant to the incident to understand what, how and why the patient safety incident happened

• Review incident report
• Review health record in detail
• Visit the location where the

incident occurred

• Review any available videos
• Locate any items involved in the incident

WHAT HAPPENED

• The mini-team coordinates and plans to conduct interviews with

those who were directly involved or associated with the incident

• An interview is often the first opportunity that a patient, family

member or health care provider has to share their detailed perspective about the patient safety incident

WHAT HAPPENED

• A detailed timeline of events is developed by the mini-team when

all the information has been gathered and reviewed

• The detailed timeline is used as a starting point for identifying

system-based factors underlying the patient safety incident

WHAT HAPPENED

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• The mini-team reviews existing policies and procedures to establish

the documented organizational expectations related to care and to provide a baseline to evaluate current organizational practices in relation to current evidence and leading practice guidelines

• Previously reported similar incidents or near misses reported

internally or by other organizations may also be identified by the mini- team

• These incidents can assist the team in understanding contributing

factors and developing recommended actions

• The mini-team conducts an environmental scan of current practices in

similar organizations and a literature review to provide context for the incident as well as determine if there are any leading practices or evidence-based guidelines relevant to the incident

WHAT HAPPENED

• As the mini-team begins to understand the incident

circumstances, contributing factors and relationships begin to emerge

• The team uses diagramming to help them identify and

understand the interrelationships between and among contributing factors

– Tree diagram – Fishbone diagram – Constellation diagram

HOW AND WHY IT HAPPENED

• Once the mini-team has completed the analysis, a summary of

what was found is prepared to clearly articulate the contributing factors related to the incident and provide the backbone for development of recommended actions

SUMMARIZING FINDINGS

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DEVELOPING RECOMMENDED ACTIONS

• Completed incident analyses are presented by the mini-team during a

weekly meeting

• Large team discussions about what could be done to reduce the risk
• f recurrence and make care safer and what was learned are key to

developing recommended actions

• Recommended actions are vetted through the Mental Health and

Addictions Service’s Executive and Operations Committees for approval

• Program leaders monitor the feasibility and effectiveness of

recommended actions being implemented secondary to patient safety incident analyses

MANAGING RECOMMENDED ACTIONS

• The Mental Health and Addictions Patient Safety Incident Analysis

Team shares and communicates resulting learning and improvements broadly with others

– Patients & Families – Health Care Providers – Health Care Administrators

• Patient safety incident analysis report summaries are shared both

within and outside the organization

SHARING OUR LEARNING

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• Mental health and addictions patient safety alerts are sent to

relevant organizations to help to make mental health and addictions care safer for others

• The Mental Health and Addictions Patient Safety Incident Analysis

Team regularly conducts presentations at local, provincial, national and international conferences

• Scholarly publications are currently being developed by the team to

spread safety learning and care improvements with a wider audience of stakeholders-clinicians, educators, researchers, policy makers

SHARING OUR LEARNING COMPLETED INCIDENT ANALYSES

• The success of patient safety incident analysis depends heavily on a

team approach

• Collaborating with patients and families in conducting patient safety

incident analyses strengthens the effectiveness of analysis in enhancing the safety and quality of patient care

MESSAGES FOR OTHERS

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• Accreditation Canada (2015). Mental Health Standards. Ottawa: Ontario
• Brickell, T.A., Nicholls, T.L. Procyshyn, R.M. McLean, C., Dempster, R.J., Lavoie,

J.A., Shalstrom, KJ.M., Tomita, T.M. & Wang, E. (2009). Patient safety in mental

• health. Edmonton, Alberta: Canadian Patient Safety Institute and Ontario Hospital

Association.

• Canadian Patient Safety Institute (2012). Canadian Incident Analysis Framework.

Edmonton, AB.

REFERENCES