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health related decisions. A patient who knows exactly what medications are prescribed, what the medication is for and also feels comfortable communicating with healthcare professionals might notice when a wrong medication is about to be given or when the dosage is incorrect and intercept the error. 58 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 105 Transparency When things go wrong…patients have a right to expect: ‒ An explanation of what happened ‒ An apology if an error was made ‒ Assurance that something will be done to prevent it from happening again Transparency is vital to creating a culture of safety. Patients should expect full access to their medical record, full explanation of all pricing/costs and open discussion of true outcomes. Safety experts and patient advocates agree that patients have a right to know all about their care, especially when things go wrong. Full explanation and complete honesty is the only way to deal with an error. When a medical error occurs, addressing the error should be focused on identifying factors that contributed to the error, rather than assigning blame to the person associated with the error (Riley, 2009). Slide 106 Understanding Error Statement: The nurse gave the wrong drug. WHY? Statement: Because she misinterpreted the name of the drug ordered by the doctor. WHY? Statement: Because the doctor was tired and it was the end of the day; the nurse had already asked him to repeat several sentences and she didn’t want to appear incompetent. Continued… Better understanding of the quality, safety and system problems encountered in the provision of care will allow focused application of patient safety solutions, including teamwork and effective communication. Understanding how and why a medical error occurred requires that the issue be examined. 59 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 107 Understanding Error WHY? Because she knew that he was known to have a temper and would shout at her. WHY? Because he was tired from a full patient appointment schedule and 3 emergencies and still had notes to complete. WHY? Because…. One should look beyond a medical error and understand that there may be many factors associated with the error. To understand an error one must ask questions about the underlying factors and encourage others to consider an error from a systems perspective. Slide 108 Culture of Safety “WHY DID IT HAPPEN?” rather than “who did it?” Asking ‘what happened’ rather than ‘who was involved’ is a methodology utilized to keep discussions about causes focused on the system rather than the person. Slide 109 A systematic process used to address problems and identify the underlying causes associated with variation in performance Root Cause Analysis (RCA) is an important component of quality improvement. It is a systematic process used to address problems and identify the underlying causes associated with variation in performance. The most important aspect of RCA is the use of a systematic approach in the examination of errors which removes focus from the individual involved in the error. The identification of causative factors allows formation of an action plan to identify strategies an organization can employ to prevent future occurrences. 60 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 110 ROOT CAUSE ANALYSIS Must Be: CREDIBLE To be thorough an RCA must be thorough and credible. A thorough RCA offers: • Determination of related human and other factors; • Determination of related processes and systems; • Analysis of underlying cause and effect systems through a series of “why” questions; • Identification of risks and other potential contributions; and • Determination of potential improvement in processes or systems. A credible RCA: • Includes participation by organizational leadership as well as those most closely involved in the processes and systems; • Is internally consistent; and • Includes consideration of relevant literature. Slide 111 ROOT CAUSE ANALYSIS PROCESS Form a team to conduct analysis Answer the questions: ‒ What happened? ‒ How did it happen? ‒ Why did it happen? ‒ What should be done to prevent it from happening again? The first step in the root cause analysis process is the formation of a team to answer the relevant questions: What happened? How did it happen? Why did it happen? What should be done to prevent it from happening again? 61 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 112 ROOT CAUSE ANALYSIS Collect as much FACTUAL information as possible Collecting factual information includes: • Establishing what happened and how in detailed, chronological order; • Collecting as much information as possible from: written and computer records; personal testimony from those directly and indirectly involved (patients, relatives and colleagues). • Determining what the impact was or what it could have been. Slide 113 ROOT CAUSE ANALYSIS Why did it happen? Establish the main and underlying reasons contributing to why the event happened. Consider, for example, the professionalism of the team, the lack of a system or a failing in a system, lack of knowledge or the complexity and uncertainty associated with the event. Try to avoid simply focusing on superficial causes of events (for example, 'I forgot to pass on an important message about the condition of an elderly diabetic patient to the practice nurse'). Alternatively, if it is a positive event, what were the underlying factors that contributed to a successful outcome? 62 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 114 ROOT CAUSE ANALYSIS What was learned as a result of the occurrence? Outline the learning needs identified from the event. Demonstrate that reflection and learning have taken place on an individual or team basis. Consider, for example: - a lack of knowledge and training - the need to follow systems or procedures - the importance of team working or effective communication. Slide 115 ROOT CAUSE ANALYSIS + = What was learned as a result of the occurrence? Outline the learning needs identified from the event. Demonstrate that reflection and learning have taken place on an individual or team basis. Consider, for example: - a lack of knowledge and training - the need to follow systems or procedures - the importance of team working or effective communication. 63 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 116 Move the Focus from Errors to Safety The Agency for Healthcare Research and Quality (AHRQ) has determined that medical errors result most frequently from systems errors, health care delivery organization and the service delivery process. Health care professionals have historically viewed errors as a sign of the individual practitioner’s incompetence or recklessness. Rather than utilizing errors to improve systems and prevent reoccurrence, health care professionals were hesitant to admit mistakes or discuss “near misses” for fear of professional censure, administrative blame or personal embarrassment. Slide 117 Move the Focus from Errors to Safety Another habit that dies slowly is the tendency to blame and punish individuals when they make a mistake. Although the science is irrefutable that almost all errors are caused by system failures, it has proved difficult for doctors and nurses to really accept this concept and to create a non-blaming environment. It is still unsafe to talk about your mistakes and the response is still to blame the individual rather than seek the underlying system failures. 64 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 118 REPORTING Reporting of medical errors and near