UCLA Head & Neck Surgery Patient Safety and Quality Improvement: - - PowerPoint PPT Presentation

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UCLA Head & Neck Surgery Patient Safety and Quality Improvement: - - PowerPoint PPT Presentation

Nov 27, 2022 305 likes •480 views

UCLA Head & Neck Surgery Patient Safety and Quality Improvement: Root Cause Analysis and Action 9/11/19 Brooke M. Su-Velez, MD, MPH QI Resident Representative 1 2 The Quadruple Aim 3 Goals of PS/QI 1. Organizational culture of safety

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UCLA Head & Neck Surgery Patient Safety and Quality Improvement: Root Cause Analysis and Action

9/11/19 Brooke M. Su-Velez, MD, MPH QI Resident Representative

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The Quadruple Aim

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Goals of PS/QI

  • 1. Organizational culture of safety
  • Encouraging questions and concerns
  • Accountability
  • Negotiation and communication
  • 2. Learning systems and improvement
  • Measurement and transparency
  • Continuous learning
  • Evidence-based practices

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Swiss cheese model of accident causation

  • Harm is caused by a series of systemic failures in the presence
  • f hazard.
  • A front-line provider may be cause of the active error, but the

real root causes of the error have often been present within the system for a long time.

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Root Cause Analysis

Factors that influence health care outcomes:

  • Institutional context
  • Organizational and management factors
  • Work environment
  • Team factors
  • Individual staff members
  • Task factors
  • Patient characteristics
  • There can be more than one root cause
  • Analysis allows for targeted action

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Five Whys

  • Why did the patient receive the wrong medication?

The nurse did not complete patient identification. Why?

  • The patient did not have a wristband. Why?
  • The wristband had been removed for a procedure and not
  • replaced. Why?
  • The printer for the wristbands was not working. Why?
  • ROOT CAUSE: The staff needed to support IT had

been reduced and was overworked.

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RCA Steps

  • 1. Understand what happened, how, and when
  • Flow diagram
  • 2. Identify any gaps in knowledge
  • 3. Collect more information
  • Cause and effect (fishbone) diagram
  • Literature search
  • 4. Create a causal statement
  • 5. Action plan

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RCA – Fishbone Diagram

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Causal Statement

The cause: “This happened…” The effect: “…which led to something else happening…” The event: “…which caused this undesirable outcome.”

  • Clearly show the cause and effect relationship.
  • Use specific and accurate descriptors for what occurred.
  • Human error must have a preceding cause.
  • Violations of procedure are not a cause and must have a preceding

cause.

  • Failure to act is only causal when there is a pre-existing duty to act.

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RCA Steps

  • 1. Understand what happened, how, and when,
  • Flow diagram
  • 2. Identify any gaps in knowledge
  • 3. Collect more information
  • Cause and effect (fishbone) diagram
  • Literature search
  • 4. Create a causal statement
  • 5. Action plan

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Action Plan for Systems Change

  • Create redundancy, such as using double checks or backup

systems

  • Use forcing functions
  • Change the physical architecture
  • Update or improve software
  • Cognitive aids, such as checklists, labels, or mnemonic devices
  • Simplifying a process
  • Educating staff
  • Developing new policies
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Example case

63F with history of breast cancer and choledocholithiasis c/b biliary stent, PPD0 s/p ERCP in PACU. Reported

  • nset of facial and lip swelling about 15 minutes after

arrival in PACU. Patient reporting voice changes.

Page received Called back Called for scope OR front desk Bronch requested Bronch received Airway assessed 2 scopes used earlier in the day <5 min Scrub out of OR 7 min 9 min 28 min No H&N scopes available 35 min 40 min

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References

  • Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality

Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

  • Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770.
  • American College of Healthcare Executives and IHI/NPSF Lucian Leape Institute. Leading a

Culture of Safety: A Blueprint for Success. Boston, MA: American College of Healthcare Executives and Institute for Healthcare Improvement; 2017.

  • Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and

Effective Care [white paper]. Cambridge, Massachusetts: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.

  • IHI/NPSF. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston,

MA: IHI/NPSF; 2015.

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