Location of Critical Incident 60 50 40 # of CIs 30 (n=109) 20 - PowerPoint PPT Presentation

Location of Critical Incident 60 50 40 # of CIs 30 (n=109) 20 10 0 Inpt Outpt NICU ED PICU Other Location

Initiating Incidents • Many CIs involved a real or potential poor patient outcome • Most common – Medication error – Mismanagement – Inaccurate patient assessment – Poor communication – S ystems failure

Initiating Problems Management Error Med Error Evaluation problem Knowledge gap Documentation System I ssue Discoordination Procedure Sign-off 0 5 10 15 20 25 30 % of CI with problem

Critical Incident Themes Family Communication Advocacy Empathy Listening Delivering Bad News Cultural Competence Difficult patient 0 5 10 15 20 Percent of CIs with Theme

S kills/ Attributes Reinforced by CIs • CIs often reflect a resident’ s growing appreciation of a specific professional skill or attribute, e.g.: – S taying calm – Maintaining focus – Trusting self – Both feeling and controlling grief

S kills/ Attributes Reinforced by CIs Diligence Clear Communication Self-trust Attribute Vigilance Persistence Other-trust Asking for help 0 5 10 15 20 25 Percent of CI s with attribute

S ummary: Most Common CI problems Problem Percent Competency of CIs Domain(s) Communication with team, Com 59 families, or written in chart Patient management or PC 44 evaluation Medication errors S BP 21 Knowledge/ skill gap MK 18

Most Common Personal Themes Personal Themes Percent of CIs Commitment to focus or persistence: 41 vigilance, diligence, avoiding distraction Balancing self-trust vs. trusting others 26 Managing stress or emotion to enhance 24 patient care: grief, frustration, embarrassment, empathy