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

APNA 29th Annual Conference Session 4012: October 31, 2015 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 DISCLOSURE • The speaker has no conflicts of interest to disclose OBJECTIVES 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 Kirwan 1

APNA 29th Annual Conference Session 4012: October 31, 2015 ST. MICHAEL’S • 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 Photo: Katherine Cooper St. Michael’s COLLABORATION WITH PATIENTS & FAMILIES • 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 PATIENT SAFETY INCIDENT MANAGEMENT • St. Michael’s utilizes a structured patient safety incident management approach to conduct the PATIENT SAFETY INCIDENT immediate and ongoing activities following all patient DID NOT REACHED safety incidents that could REACH PATIENT PATIENT have resulted, or did result in unnecessary harm to a HARM patient NEAR MISS INCIDENT NO HARM INCIDENT Kirwan 2

APNA 29th Annual Conference Session 4012: October 31, 2015 PATIENT SAFETY INCIDENT ANALYSIS • 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? MENTAL HEALTH & ADDICTIONS TEAM • The Mental Health and Addictions Patient Safety Incident Analysis Team was 1 CNS established in 2010 5 5 MPATIENTS FAMILY MEMBERS • The team is comprised of 20 members – 10 patient or family members 2 2 SOCIAL PSYCHIATRISTS WORKERS – 10 mental health and/or addictions clinicians • A Clinical Nurse Specialist 2 1 OCCUPATIONAL PHARMACIST THERAPISTS and an individual with lived experience co-chair the 2 REGISTERED NURSES committee MENTAL HEALTH & ADDICTIONS TEAM • The team is tasked with analyzing all patient safety incidents that can occur 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 Kirwan 3

APNA 29th Annual Conference Session 4012: October 31, 2015 RECRUITMENT OF PATIENTS & FAMILIES • 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 ONBOARDING 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 INCIDENT ANALYSIS APPROACH • 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 Kirwan 4

APNA 29th Annual Conference Session 4012: October 31, 2015 WHAT HAPPENED • 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 Kirwan 5

APNA 29th Annual Conference Session 4012: October 31, 2015 WHAT HAPPENED • 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 HOW AND WHY IT 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 SUMMARIZING FINDINGS • 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 Kirwan 6

APNA 29th Annual Conference Session 4012: October 31, 2015 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 of 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 MANAGING RECOMMENDED ACTIONS • Program leaders monitor the feasibility and effectiveness of recommended actions being implemented secondary to patient safety incident analyses SHARING OUR LEARNING • 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 Kirwan 7