[How to investigate and analyze clinical incidents: a clinical risk protocol in association with litigation and risk management]

Clinical care review systems in healthcare: a systematic review

Background

Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review.

Methods

A librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction.

Results

We found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review.

Conclusion

While guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation.

Electronic supplementary material

The online version of this article (10.1186/s12245-018-0166-y) contains supplementary material, which is available to authorized users.

Accidental injection of patent blue dye during gynaecological surgery: Lack of knowledge constitutes a system error

The authors report a case in which an intravenous injection of Patent Blue V dye instead of Indigo Carmine was given during routine gynaecological surgery. The patient presented with temporary arterial (spurious) desaturation and skin discoloration over a 48-hour period. Pharmacological differences between these dyes are described. Root cause analysis based on the ALARM (Association of Litigation and Risk Management) model is presented. The authors emphasise that use of this model should not be limited solely to describing and correcting well known systems errors such as working conditions or teamwork and communication. Furthermore, they conclude that insufficient knowledge must also be recognised as a systems error and as such should be sought out and corrected using similar strategies to those used to discover other contributory factors, without allocation of blame to any individual.

Risk assessment analysis of the future technical unit dedicated to the evaluation and treatment of motor disabilities

OBJECTIVES

The National Hospital of Saint Maurice (HNSM) for Physical Medicine and Rehabilitation aims at strengthening its position as a pivot rehabilitation and physical therapy center. The opening in 2011 of a new unit for the evaluation and treatment of motor disabilities meets this objective. This project includes several parts: clinical, financial, architectural, organizational, applied clinical research as well as dealing with medical equipments and information system. This study focuses on the risk assessment of this future technical unit.

METHODS

This study was conducted by a group of professionals working for the hospital. It started with the design of a functional model to better comprehend the system to be analyzed. Risk assessment consists in confronting this functional model to a list of dangers in order to determine the vulnerable areas of the system. Then the team designed some scenarios to identify the causes, securities barriers and consequences in order to rank the risks.

RESULTS

The analysis targeted various dangers, e.g. political, strategic, financial, economical, marketing, clinical and operational. The team identified more than 70 risky scenarios. For 75% of them the criticality level was deemed initially tolerable and under control or unacceptable. The implementation of an action plan for reducing the level of risks before opening this technical unit brought the system down to an acceptable level at 66%.

CONCLUSION

A year prior to opening this technical unit for the evaluation and treatment of motor disabilities, conducting this preliminary risk assessment, with its exhaustive and rigorous methodology, enabled the concerned professionals to work together around an action plan for reducing the risks.

[Obstetric epidural analgesia: systemic analysis of an error of syringe rate programming]

We reported an error of syringe rate programming during maintenance of obstetric epidural analgesia and its systemic analysis. The epidural solution included ropivacaine and sufentanil. Despite the 60 mg ropivacaine and the 9.6 microg sufentanil doses infused in 45 minutes, no maternal systemic effect was noted. The systemic analysis of this near-miss has revealed a health care system error.

[Accidental intravenous injection of potassium chloride: analysis of contributing factors and barriers to risk reduction]

Errors linked to injectable potassium chloride (KCl) have been the cause of deaths which have occurred for many years. Following an accidental direct intravenous injection of KCl of no clinical consequence for the patient, we have analyzed the contributive factors, established an action plan to prevent this risk and finally assessed its impact. Among the causes leading to medication errors, we have identified those linked to the handling of the drugs by nurses, the team, the work conditions, the organization, the institutional context and finally to the drug itself. The risk reduction procedure involved a withdrawal of injectable KCI ampoules from wards, possible in 52% of the care units, a reorganization of storage for the others. The subsequent monitoring of floorstocks revealed that these measures were insufficient and that the risks prevailed due to the presence of KCI ampoules in drawers assigned to other ionic solutions. A study carried out among the medical and nursing personnel revealed that 61.2% of the doctors thought that the risk existed in their ward and 68% of the nurses considered themselves to be exposed to the risk of a medication error. The drug supply chain of our institution, as in numerous others, is not safe. Hospitals are not yet organized adequately to prevent the occurrence of such an error. The comparison with foreign organizations of drug dispensation allows us to think that the improvement and professionalization of the drug supply chain will both be assets in the prevention of such medication errors.

[How to analyze an incident of the transfusion chain]

Incidents and accidents analysis is one part of risk management in healthcare organisations. It is based on methods such as healthcare process analysis and the Association of Litigation and Risk Management (ALARM) method, to understand not only immediate causes but also root causes. The goal is to implement relevant remedial and preventive actions to secure healthcare processes. The hospital's risk management unit has to be involved in the methodological analysis of every grade zero transfusion incident. The system is based on a retrospective analysis process in compliance with the French National Authority for Health's ongoing requirements for risk reactive approach, allowing to identify failures and start relevant actions. Healthcare teams should overcome difficulties in order to be totally involved in the process. Human factors recognition, establishment of clear and effective communication between individuals and critical points of control should provide optimum quality care services that are safe and free of unnecessary risks.

[Morbidity/mortality review: usefulness and shortcomings]

GOAL

The Morbidity-Mortality Conference is a formalized exercise validated by the Haute Autorité de Santé (HAS) whose aim is to improve the quality and safety of care through periodic (weekly or monthly) analysis of deaths and complications. In France, no data is available concerning the implementation of the MMC methodology despite the interest of the National Institute of Healthcare Quality (HAS) in using the MMC as part of the physician recredentialling process and of hospital accreditation (mandatory in France since the laws of 2005 and 1997 respectively). We aimed to study the experience and perceptions of physicians with this specific methodology in the context of a large regional project aimed to improve clinical risk management.

METHODS

A one page questionnaire with eight confidential questions and a space for free commentary was sent to 150 hospitals in the north of France.

RESULTS

We received 83 responses from 29 hospitals (range: 1-14 responses per hospital). Analysis of unexpected adverse events is performed mainly in informal meetings (76%) and mandatory reports (77%); the MMC methodology is rarely used (11%). The analysis of adverse events is considered to be an important tool for the improvement of patient care and safety (90%) and continuing education (61%), and it results in modification of care protocols (70%) or organizational change (71%). Lack of knowledge of the MMC methodology (66%) and lack of available time (50%) are the main obstacles to the adoption of the MMC. Fear that the findings of the MMC could be available for use in litigation (1%) was not an obstacle. Physicians interested in implementing the MMC are motivated by a desire for improved patient safety (86%) and care management on the surgical service (54%). Self-responsibility is more important than the mandatory process for re-credentialing.

CONCLUSION

The implementation of the MMC requires specific measures such as teaching and support.

[Systemic analysis using ALARM process of two consecutive incidents during anaesthesia]

Compulsory professional practice evaluation will require holding frequent morbidity mortality staffs. Those staffs must follow strict methodology. We report successive steps of systemic analysis according to ALARM process of two successive non lethal anaesthetic incidents. Such analysis helped identifying care management problems and their systemic causes. Thus it leaded to corrective measures in order to prevent such events recurrence. Moreover, it allowed systemic defaults correction that prevent future other accidents.