Action Plan
An Action Plan is the result of Root Cause Analysis. The Action Plan addresses system and process deficiencies; improvement strategies are developed and implemented. The plan includes outcome measures to indicate that system and process deficiencies are effectively eliminated, controlled, or accepted.
The goal of the Action Plan is to find ways to prevent repeat of adverse events or close calls.
Adverse Events
Adverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic or other facility. Adverse events may result from acts of commission or omission (e.g., administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.). The type of review that the event receives is determined through the Safety Assessment Code (SAC) Matrix scoring process. Some examples of more common adverse events include: patient falls, medication errors, procedural errors/complications, completed suicides, parasuicidal behaviors (attempts/gestures/threats), and missing patient events.
Close calls (Near miss)
A close call is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Such events have also been referred to as near miss incidents.
Close Calls are opportunities for learning and afford the chance to develop preventive strategies and actions. Close Calls receive the same level of scrutiny as adverse events that result in actual injury. As with adverse events, all Close Calls require reporting and documentation in the NCPS Patient Safety Information System, and the SAC Matrix scoring process determines the type of review done on a close call.
Intentional unsave acts
Intentional unsafe acts, as they pertain to patients, are any events that result from:
Intentional unsafe acts should be dealt with through other methods, i.e., Administrative Investigation (AI) or other administrative channels as determined by the facility.
Root Cause Analysis
Root Cause Analysis is a process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or close calls. RCAs have the following characteristics:
To be thorough, an RCA must include:
To be credible, an RCA must:
Sentinel Events
Sentinel events are a type of adverse event. Sentinel events, as defined by Joint Commission, are unexpected occurrences involving death or serious physical or psychological injury, or risk thereof. Serious injury specifically includes loss of limb or function. Major permanent loss of function means sensory, motor, physiologic, or intellectual impairment not previously present that requires continued treatment or life-style change. The phrase risk thereof includes any process variation for which a recurrence would carry a significant chance of serious adverse outcomes. Sentinel events signal the need for immediate investigation and response.
Some examples of sentinel events include:
Refferences:
Department of Veterans Affairs US