In this video, we're going to talk about sample event review meetings. Event review team meetings provide a collaborative space for identifying system issues. They can be designed in two ways, Comprehensive Systematic Analysis or Near Miss and Low Harm Meetings. CSAs tend to focus on high harm or sentinel events. A variety of tools can be used for a CSA including a Root Cause Analysis or Fault Tree Analysis tool. These tools take a systems approach to identify both active and latent failures. Near Miss and Low Harm Meetings though tend to have a multi-disciplinary group who triages events and identify emerging trends prior to causing harm. These groups work to hold folks accountable for following up on events and they work with stakeholders across the organization. These groups may also serve as a safety star or good catch nominating committee. We're going to watch two review meetings. So welcome everyone to our monthly multi-disciplinary event review meeting. Irene, you want to kick us off? Sure. You should have a copy of the packet in front of you. If you look at the number of events recorded for the month of July, we had 386 events. You can see we must be getting safer since the number of events is decreasing. In January, we had 400 events reported. If you look at how many events are recorded by harm score, you could see that we only had one of that in which the patient died and 10 events in which severe harm occured to the patient. So we have 11 serious events in this month? That seems like too many, Irene. I think we need to send an email to staff and tell them to be more careful and remember to follow the policies. And we're starting to have zero harm events and zero safety events like high- reliability organizations. Good idea. If you look to the second page in your packet, you can see that the portion of events by reporter role, nurses report the most events and pharmacists and technicians are right behind them. If we look at the percentage of events reported by category, we can see that the category "Other" is still our largest with 29% of our events and 24% of our events are made up of medication and substance events. When we look at the benchmarking data for False though, we can see that the work of our False Committee must be working because our fall rate has decreased compared to other peer organizations. Great. Kudos to the False Group. I just wish we knew more about this Other categories so we could try and fix those safety concerns. Was anyone have an event they would like to discuss? I have one. Last week we have event in which our resident oral medication's on the wrong patients. This was concerning as our patient identification process about. That sounds like a physician issue to me. I think we could just move on to the next event. Yes. I agree. I think the attending physician involves counseling a resident. Okay. All right, good morning everyone and welcome. This is our monthly multi-disciplinary event review meeting. Do we have any guests today or announcements? I do. I have Pete, who's one of the MRI technicians who reported Event 645. And I just wanted to let everyone know that the LIS is going to be down on Friday from 3:00 am-6:00 am. So, downtime procedures are going to be in place and that means using the paper forms as well. I just want to remind folks that these discussions are permitted privileged and confidential and that conversations and documents must stay in the room. So please leave you're packets in the middle of the end and we will shred them. And you want to get it started? Sure. If you reference the packet in front of you, we have a Safety Star nomination today. It's on the second page of your packet. This is for a technician named Jessica, who went into the patient's room for vital rounds, while taking the patient's vital, she noticed on the patient's right breast that the patient was wearing a purple fall breast arm band and a patient identification band from another hospital. But when on her left breast, she was wearing an arm band from our hospital. Jessica alerted the care team reporting that it could be confusing since purple bands in our hospital represent a DNR status. So this event is also slated for review at our hospital's Patient Identification Committee. The State Patient's Safety Center has requested all I have spoken for a standardized bands to avoid confusion. We are working with the meeting to ensure there is a process in place that all bands from [inaudible] hospital are removed and our hospital bands are placed upon arrival. This will also be double checked as part of the nurse's assessment. Great. Excellent. If there's not anymore discussion, let's vote. All in favor of awarding of Safety Star to Jessica, please raise your hands. Can I go? Sure. All right. Great. We will invite Jessica to our next Patient Safety Committee to receive her award. Okay. Next up in your packet was an event that we discussed last month. Event Number 589. This was an event in which the patient fell while walking to a group therapy session and in the event the reporter recommended that hand hygiene dispensers be fixed so that the Purell doesn't drop on the floor. One of our action items was that we were going to follow up with Facilities and Central Supply to see if hand sanitizer could be switched to a different product so that it doesn't leak or if trays could be installed so that hand sanitizer won't leak on the floor. I think we do have some additional follow up on this event. I do. I heard from Donna, our Psychiatry Department rep that they were able to work with the facilities and they're going to be installing trays underneath the wall-mounted Purell dispensers so that the hand sanitizer does not drip on the floor. And what I made is they're working to make this change in the whole hospital. They're starting with areas that have patients that are mobile like Psychiatry and Post Traumatic Rehabilitation. So I think that's a really great systems change and maybe we can include that in our next month Systems Change Report. Wonderful. All right. So the next event in your packet is a new event. It's Event 678. In this event, a case was posted for a humeral rod instead of a femoral rod. The patient was marked on her right humer instead of femor. I inform the nurse that the consent was not corrected to Patient to Care Team for verification. The attending entered and asked the patient, "Have you been marked?" She replied, "Yes. But on my right arm and I don't know why I'm marked on my arm." The attending then re-marked to the patient. The recommendations in this event say that this was a close call which indeed it was. And to ensure information on the posting is correct, does this caused the delay in starting the procedures. The room and the supply setup was wrong. This event is interesting. Does anyone know why the posting information was incorrect? Well, I have some insight on this one. We think that it's, we suspected it's because the medical systems are manually copying it. I can follow up with status system confers with the case. But this has me thinking and wondering if we can pull this information automatically from the electronic medical record. I can check with our IT Colleagues to see if we have the ability to automate this and let's sure about next week. And maybe we can also check to see what the consent said and let's bring this back next week since this was a really big Near Miss. Okay. Great. Thank you. So the next event in your packet is event 645. And for this event, we have the frontline reporter here. Pete? Welcome. Do you want to tell us a little bit about the event? Sure. The patient was scheduled for our large-bore three Tesla scanner. And so the provider place the order and they only had make and model information for stents that were placed in the patient. cardiac stents that were placed in the patient in 2015. And these were put in at another hospital and we didn't have any other information for any other stents. The patient have number of stents. So the radiologist said that that was also there, looked up with patient's previous CT scan and they could clearly see the number of stents that are there. Obviously, this is a pretty significant patient safety issue because not all stents can go in 3T scanner. And the make and model number information is necessary for us to determine which MRI scanner we put the patient in. Are other hospital areas using the same electronic medical record? I do know that a number of hospitals in the area do use the same electronic medical record. And I wonder if there is a way for us to put this information together in a database of some sort. It does take an incredible amount of time to look this information up. It's a very time-consuming process from our representative with a case like this. And sometimes the patient isn't awake or with it to be able to talk to us. We were lucky in this case if the patient was. I can pull together a meeting with our innovation hub to see if we could prototype what the database might look like and see if there is any interfaces we could leverage to help retain this information. Great. Let's compare the meetings. Hopefully, you saw that the Meeting Two was a more valuable way of using this event reporting data. In Meeting One, the team reviews graphs and events. However, the graphs that are used are not actionable. The team also incorrectly uses counts of self-reported events to demonstrate an improvement. The reality is that this group doesn't actually know if an improvement was made based of the number, if an improvement in safety was made based of the number of events submitted. The group also compares rates of events to other organizations but does not talk about any contributing factors in the fall events that they are seeing in their own local organization. In Meeting One, the overall response is a little more punitive. You hear a staff member say, "Please tell them to be more careful." They tend to use relatively low-air proofing strategies like re-education. In Meeting Two, the team reviews actual events that the safety analyst has identified after reading all events submitted for the previous period. The materials are clearly labeled as Privileged and Confidential. And the chair says that these are going to be shredded at the end of the meeting. The team also identify system issues in ways to prevent events from occurring again. It also forwards events to other committees. The team welcomes a frontline reporter to join the meeting and discuss the events. And lastly, in the second meeting, the group awards a staff member who's gone above and beyond to maintain safety. So you can see that the second meeting is a better use of this data. When participating in an Event Reporting Meeting, it's important that you listen with an open mind and actively participate, be prepared to share results of any investigations you have taken, be responsible for following up on actions you've taken, be willing to collaborate with others, and after the meeting, be careful and thoughtful in how you communicate about the event, remembering that these discussions are confidential.
