In March 2019, a Tennessee woman filed suit against Nashville-based Vanderbilt University Medical Center, claiming surgeons operated on her wrong kidney. As a result, the patient had to have a second surgery to correct the mistake, and she now needs dialysis for life. While this case was both rare and extreme, the fact remains that damaging medical errors are quite common, yet often preventable.
The World Health Organization (WHO) says more than 1 million patients die every year from surgical complications. And, there is a 1 in 300 chance of a patient being harmed during health care.
Clearly, more should be done to improve healthcare safety and quality and reduce risks to patients. Yet to say that the challenges of healthcare risk management are complex would be an understatement. Existing processes for risk management are fragmented and lack standardization. Many healthcare providers continue to use inferior systems that fail to analyze and synthesize data in a meaningful way. And all this in a rapid-fire environment, where threats can materialize in an instant.
Searching for the How and Why
When viewed as an individual benchmark, medical error reports only uncover so much. For example, an incident report of the Vanderbilt case would certainly show that the wrong site was operated on. But the more important question is Why? Perhaps the surgeon had been working too many consecutive hours. Maybe there was misinformation between departments. Or maybe a critical pre-op step, such as marking the operation site on the body, was overlooked. And if it was, why?
The how and why behind an incident are the real agents of change.
Finding the root causes behind errors in patient care is critical if we hope to prevent them from happening again. In fact, the only good that can come of such mistakes is the opportunity to learn from them and make process improvements – ultimately improving the standard of care and saving lives.
Risk Management Software for Increased Patient Safety
Reducing errors in patient care is not about having more medical knowledge, it’s about operational performance. And a basic incident report won’t change much.
When a safety event occurs, the first step is to record the basic facts in a patient’s medical record. While this step is both necessary and required, it excludes the information that is most important for analysis, learning, and operational change in the organization.
When things go wrong, both front line staff and healthcare administrators need access to comprehensive facts and circumstances surrounding the incident – as well as a clear, streamlined, and accountable improvement process. Fortunately, the right performance improvement platform can both identify and offer cues towards effective corrective and preventative actions, or CAPAs.
Hospitals, regional clinics, and surgery centers will benefit greatly from a single, comprehensive system for risk management., particularly one that integrates the many performance measures across the board, and that integrates all these activities into a goal-oriented, coherent whole. In order to keep up with the pace of care, they need analysis and synthesis of data in real-time. And most importantly, they need clear and manageable action plans based on that analysis.
The right platform for quality-safety improvement can provide insight into past incidents, identify existing performance trends, and offer a view of the future. ActionCue CI’s comprehensive dashboard facilitates the collection of information and circumstances surrounding healthcare incidents including planning errors, process errors, and failures to act.
Here are some of the key ways ActionCue CI makes quality-safety tracking and improvement more effective:
- Anyone on staff can originate an Event Report with little or no training
- There are 26 categories of events covered including Complaints/Grievances, HIPAA incidents, Abuse, Plant/Facility, Readmission, Sentinel Events, Security and Work-related Injury
- The distributed workflow not only distributes the workload but obtains inputs from the best people to do so, including those nearest to the time and place of the event
- Event Reports are passed to the next person in the workflow based on roles, permissions and assigned parts of the organization
- The workflow, appearance and experience are designed with expertise in several disciplines
- Individuals or groups have assigned responsibility for each step, but others can observe and review the content, or can be requested to confer on the content
- Workflow progress is tracked so that stalled reports are identified to managers who can send reminders
- Content (documents, photos, videos)can be uploaded/attached to the Event Report at any stage
- Alerts can be immediately sent to select individuals when content of designatedcriteria is saved
- Those with permission can track, review and research the Event Reports using a range of content filters while they are in progress or after completion
- Follow-up activities, beyond the primary track of the Event Report workflow, can be tracked in terms of scheduled reminders and information or documents exchanged, with any internal or external organization
- Built-in analytics and reports provide distribution data (histograms) of content occurrences, weighted analyses, time spent by workflow stage and event category, and much more insight, as soonas the events Reports are finalized, without any time delay or human effort.
- Certain facts and circumstances are tallied in the Event Reports to form data points used in numerous Performance Measures like Fall Rate, Medication Variance Severity, and many more
- Event Reports can be linked to Performance Improvement Action Plans, and vice versa, for easy human analysis
While some of these features may be of particular interest or importance to various users, the real power of ActionCue CI is that it was designed for a specific purpose – facilitating all stakeholders having a fundamentally different relationship with the data that allows them to better leverage their time and energy for true improvement. While the change-averse may initially balk at such a dramatic shift, it is the right approach for long-term gains throughout the organization. Optimal gains can only be achieved through a platform designed for this purpose.
Mistakes in healthcare have bad consequences for everyone, from injured patients to physicians who may face legal and professional troubles. By working to eliminate medical missteps, healthcare professionals can protect patients and themselves while lowering operational and cost inefficiencies in delivering better care. But if institutional practices do not change, nothing will change.