Scenario

 Esther,

age 87, is a resident at a Minnesota nursing home. She has been there for three years. She was able to walk with a walker when she arrived, but now needs a great deal of assistance getting in and out of bed, and generally uses a wheelchair when out of her room.

Scenario source: Oregon Patient Safety Improvement Corps Team 2007/2008 in collaboration with community and advocacy organizations

Scenario
 One

morning, Esther was being moved from her bed to a chair using a Hoyer-type Hoyerlift. She called for a CNA to help her.  As the CNA was moving her, Esther fell and suffered a serious head injury as well as some superficial scratches.  Esther was briefly hospitalized for evaluation of her head injury; a CT showed no intracranial bleeding, and she was released the next day.

Scenario
 During

an investigation following the fall, the CNA admitted that she did not follow the policy that required two staff members assist with all transfers.  The investigation found that the CNA was not compliant with the facilitys policy for transfers.  She was given a warning and re-trained reon the importance of the policy.

How do we respond?
 Look

for the individual who was at fault  Focus on training, compliance with policies BUT..  What if it happens again?  What if someone else does the same thing?  What if it goes deeper than that?

What is RCA?
 

Root Cause Analysis Structured way of looking at events from a systems perspective


 

Events are rarely just the fault of one person doing the wrong thing People operate in a system. The system can make it easier for them to do the right thing, or more difficult Have to look at multiple contributing factors If you dont uncover all potential causes, event can happen again

What is RCA?
 Grew

out of theories of accident analysis, systems design, safety engineering  Required by the Joint Commission in response to sentinel events  Required by Veterans Administration  Used primarily in hospitals, but starting to be used in some nursing homes


OR, MD, some MN facilities

 Compatible

with MDH regulatory role

What is RCA?
 Facilitated

Process  After event: gather documents, assemble basic timeline  Assemble all players  Draw out the story from all perspectives  Work to identify contributing factors


Why, why, why, why, why?

 Develop

plans of correction that address contributing factors

Scenario
 One

morning, Esther was being moved from her bed to a chair using a Hoyer lift. She called for a CNA to help her.  As the CNA was moving her, Esther fell and suffered a serious head injury as well as some superficial scratches.  Esther was briefly hospitalized for evaluation of her head injury; a CT showed no intracranial bleeding, and she was released the next day.
Scenario source: Oregon Patient Safety Commission

Scenario
 An

investigation after Esthers fall discovered the following:  The lift had been used many times before, and there were no known problems with it.  There were two lifts on the floor, but one was already in use.  Both lifts were older models that required two people to use correctly.

Scenario
 The

CNA was aware of the policy requiring two people for transfers with Hoyer-type Hoyerlifts. Before assisting Esther, she tried to find someone to help her. Of the two other CNAs on duty, both were busy helping other residents.  The CNA was running behind in her work, and she knew that Esther tended to get agitated if she had to wait very long to get help.

Scenario
 The

CNA had used this lift by herself before without incident; she believed that she could use it safely again, so she made a decision to do the transfer unassisted.  The CNA was trained in how to use the lift.  When she was transferring Esther, she had to maneuver the lift around some obstacles in Esthers crowded room; this led to Esthers feet getting tangled in the lift, making her lose her balance.

Scenario
 Contributing
 

factors for Esthers fall:

Environmental (crowded room, old lift) Staffing (other staff busy, no plan for getting assistance) Policy (no provision for situations when backup not available) Culture (acceptance of shortcuts, individual vs team approach)

Scenario
 Action


Plan:

Explore purchase of lifts that can be used by just one person, are more stable Consider assistance with transfers when developing workplans/priorities for staff Increased management follow-up to assess followeffectiveness of modified workplans Nurture team approach to care/less individualized focus on roles

Two approaches
   

Focus on individual errors  Focus on conditions that allow errors to happen Individual blame Punishing errors Expectation of perfect performance Changing systems  Learning from errors
 

Expectation of professional performance within a system that compensates for human limitations  Solutions tend to be disciplinary or focused on  Solutions might involve training, equipment, cultural training change, staffing

Whats in it for you?

Enhanced engagement/ownership by staff

Empowers staff/Fosters creativity

 

Process/systems focused Fosters more in-depth analysis in

Assists you in completing the required Vulnerable Adult documentation/analysis

Risk prevention


Staff are more proactive -Identify risks in environment

Culture Change more awareness of resident safety and how staff can impact this


NonNon-punitive (Just Culture)