During this module, the key features and main steps to analyze an incident using the comprehensive method will be described, discussed and applied. In addition, the tools that facilitate a comprehensive analysis will be introduced: the timeline, human factors, diagramming contributing factors and their interconnection (using the constellation diagram), guiding questions and the statements of findings.

1. Incident Analysis Learning Program - Module Four
Comprehensive Analysis Method
Jan. 10, 2013

2. Welcome
Ioana Popescu Sandi Kossey Erin Pollock Tina Cullimore

3. Learning Program M3
WHAT WAS LEARNED?
WHAT CAN BE
DONE?
HOW AND WHY?
WHAT HAPPENED?

4. Analysis Methods
• Canadian Incident Analysis
Framework
• Systematic Systems Analysis
• Local framework
• Other (VA, NPSA)

5. Learning Objectives
The knowledge elements include an understanding of the:
• Steps to take when undertaking a comprehensive analysis
• Benefits and limitations of different diagramming tools
• Various considerations when writing statements of
findings
The performance elements include the ability to:
• Describe the steps to create a timeline of the event
• Perform the main steps to analyze information to identify
contributing factors and relationships

6. Agenda
3-parts
• Knowledge expert
• Practice leader
• Facilitated discussion

7. Introducing: WebEx
Be prepared to use:
- Raise Hand & Checkmark
- Chat & Q&A
- Pointer & Text
7
11-Jan-13 7

8. About You M2

9. Presentation
Wayne Miller

10. Has this ever happened in one of
your facilities?
3:45 pm Call from Nurse manager – Patient has been
given the wrong medication. Patient is unconscious
and has been moved to the ICU and assessment is
ongoing.

11. Individual Perspectives to M2
Leading Practices
Key Features of Incident Analysis
• Timely, Thorough
• Objective and Impartial (avoid conflicts of interest or perceived
conflicts)
• Credible
• Interdisciplinary, Including Frontline, Patient/Family, and Non-
regulated staff
Practise / Preparing
• Who, When, and How is the analysis conducted in your
organization
• Build Teams - Quality, IT, Health Records, Bio Med
• Run simulations
• Just and trusting culture encourages, supports, and
expects the reporting of safety and learning events.

12. Page 39
Canadian
Incident
Analysis
Framework

14. Gather Information
• Caution…Do not jump to solutions, conclusions,
and assumptions.
• Caution…The team will not understand the
contributing factors related to the incident if they
do not understand the circumstances surrounding
the incident.
• Caution…The facilitator must have systematic
processes for identifying the gaps in information
and for accurately addressing those gaps.

15. WHAT HAPPENED?
• Get a Game Plan – Each Incident is different
• Gather Information
• Review the Incident (Occurrence) Report
• Review Additional information
• Create a Detailed Timeline
• Review Supporting Information

16. Review the Incident Report &
Additional information
• Triggers for a comprehensive analysis
• Incident report is based on initial understanding
• Others
• Review the health record
• Conduct interviews
• Visit the location where the incident occurred
• Secure items OR look at similar items/devices to
help build that understanding

17. Create a Detailed Timeline
Example
(p.104)

18. Review Supporting Information
• Includes:
• Review of Policies and Procedures
• Look at previously reported similar incidents
• Environmental Scan
• Literature Search
• Policies and Practices in leading organizations
• Consultation with colleagues or experts in the field.

19. HOW AND WHY IT HAPPENED?
• Analyze information to identify contributing factors
and relationships
• Uses systems theory and human factors
• Uses diagramming
• Summarizes findings

20. Analyze Information
• Build on understanding by asking questions to
determine contributing factors and relationships of
factors to the event.
• Appendix G, Page 89, Guiding Questions
• Allows lens to focus on system issues which may
have contributed to the event—rather than focus on
the person
• What was this influenced by?
• What else affected the circumstances?

21. Use Systems Theory and Human
Factors
Systems Theory
Focuses on an assessment of
the individual’s action within
the context of the
circumstances at the time,
NOT on the individual alone.
Human Factors
Interaction between the
human and the system

22. Use Diagramming
• Identify and understand
inter-relationships between
and among contributing
factors
• Provides a map which, when
used correctly, helps the
team identify the “route”
which was taken and why it
was taken.
• Shifts the focus from the
person to the system in
which the person works.

23. Diagramming—Ishikawa
Diagram

24. Diagramming—Tree Diagram

26. Constellation Diagramming—5
steps
• Step 1: Describe the incident
• Step 2: Identify potential contributing factors
• Step 3: Define inter-relationships between and
among potential contributing factors.
• Step 4: Identify the findings
• Step 5: Confirm the findings with the team

28. Guiding Questions
Appendix G (p. 89)
Example

29. Summarize Findings
• Statements of findings
• Describe the relationships between the contributing
factors and the incident and/or outcome.
• Three categories of findings:
 Factors that if corrected would likely have prevented
the incident or mitigated the harm.
 Factors that if corrected, would NOT have prevented
the incident or mitigated the harm, but are
important for patient/staff safety or safe patient care
in general
 Mitigating factors—factors that didn’t allow the
incident to have more serious consequences and
represent solid safeguards that should be kept in
place

30. Statement of Findings
Example
“The use of gravity intravenous infusion
sets in the Emergency Department
increased the likelihood that an
intravenous narcotics infusion would be
infused at a higher than intended rate
when the patient changed his position on
the stretcher”

31. Confirm Findings
Team should agree on the findings before developing
recommended actions
Work through disagreements to achieve consensus
If key individuals who were involved in the event were
not part of the analysis team, ask for their feedback
on the findings.
Include a Back-Checking Step

32. Ultimate Goal
To
WHAT CAN BE DONE TO REDUCE THE RISK OF
RECURRENCE AND MAKE CARE SAFER

33. WHAT WAS LEARNED?
Healthcare providers work very hard to provide safe
care in the best way they know how.
Let’s not ask them to do this risky work without a net

34. Real-life Experience
Dr. Chris Hayes

35. Incident Analysis Framework:
Real-life Experience
Module 4: Comprehensive analysis method
January 10, 2013

36. What is critical incident
(ie. a severe harmful patient safety incident)
• Any unintended event that occurs when a
patient receives treatment in the hospital,
– that results in death, or serious disability,
injury or harm to the patient, and
– does not result primarily from the patients'
underlying medical condition or from a known
risk inherent in providing the treatment

37. What is critical incident
(ie. a severe harmful patient safety incident)
• Not factored into event that occurs when a
Any unintended the definition at St.
patient receives treatment in the hospital,
Michael’s
– perspective of patient outcome is considered
– that results in death, or serious disability,
first….harm feels like harm!!
injury or harm to the patient, and
– assumes inherent risks are fixed with no
– potential in learning or reducing…eg CLI
does not result primarily from the patients'
– data supports inherent risk of or fromd/t known
underlying medical condition death a
adverse events providing the treatment
risk inherent in = 1/116

38. An example
• Patient admitted to the ICU following a large stroke. At
approximately midnight the patient began having generalized
seizures. She paged the resident on call. The resident came and
asked for some Ativan. As the resident was giving the Ativan he
asked the nurse to quickly get some Dilantin (phenytoin). The nurse
left the bedside to prepare the medication in an IV minibag, returned
to the bedside and began to hang the drug. Meanwhile the Ativan
had stopped the seizure and the resident returned to his call room.
• 20 minutes later the patient’s blood pressure rose to 230 over 120
mmHg. The patient began complaining of chest pain and was
visibly short of breath. The nurse paged the resident to the bedside
STAT. The resident on arrival asked for some IV metoprolol. He
gave 20mg in total with little effect on the blood pressure.

39. An example
• Eventually the patient was stabilized but had suffered a large heart
attack and now had significant congestive heart failure.
• Later that evening the resident noticed a vial of phenylephrine at the
patient’s bedside. He showed this to the nurse who became
immediately very upset and was later sent home.
• The Charge Nurse reported the incident later that evening, the
family was informed of the incident and received an apology
• Risk Management & QI team reviewed the incident details and
decided that a comprehensive review be conducted

40. So it’s an adverse event
• The next phase is to analyze the event in
order to know:
– What happened
– How and why it happened
– What can be done to reduce the likelihood of
recurrence and make care safer
– What was learned

41. Conducting the analysis

42. Conducting the analysis
Date / Time Information item Comment / Source
Jan 1, 12 22:45 Patient admitted with stroke Patient record
23:35 Patient develops GTC seizure Nurses notes, confirmed by
nurse interview
23:40 Resident assessed, gave Ativan and verbally Patient record, confirmed by
ordered Dilantin 1g over 20 min resident interview
23:55 Nurse finished preparing, hung and administered Patient record, confirmed by
Dilantin nurse interview
Jan 2, 12 00:20 Patient blood pressure noted at 230/120, requring Patient record
more oxygen
00:50 Patient’s BP resolved but requiring more oxygen Patient record
~01:20 Bottle of phenylephrine discovered at bedside Interview with resident
~01:50 Bedside nurse relieved of duty and went home Interview with charge nurse
10:30 Echo done and shows Grade 3 LV Patient record

43. Conducting the analysis

44. Conducting the analysis
Verbal order Acute issue, middle of
given night
Patient suffers
large MI and CHF
following wrong
drug
administration
Nurse had to
Double-check policy Sound-alike, look leave bedside to
does not include alike drugs stored prepare med
anticonvulsants together

46. “Swiss Cheese” model
Medication Manufacturer
organization
Hazards
Sound-alike
look-alike
drug
Purchasing
Losses
CHF/MI RN/MD Double-check

48. What did we do?

49. What did we do?

50. Recommendations / Actions
• Introduced TallMan lettering
• Removed multi-drug bins and reorganized med
cabinets
• Moved phenytoin under “D” for dilantin
• Did the same for all other ICUs, then all wards
• Met with Clinical Services Committee and
Pharmacy re purchasing of sound-alike, look-
alike drugs
• Discussed the problem and the solution openly

51. Recommendations / Actions

52. Summary
• Incident analysis is a standard process to learn what,
why and how an patient safety incident occurred
• An interprofessional, open and just approach fosters
greater learning
• Requires gathering of material facts and interviews of
those involved
• Requires open exploration of all contributing system
factors
• Done right…leads to effective recommendations and
improvement in patient safety

53. Case Study – Virtual Group Exercise

54. Breakout Session
Most participants will
“move” to breakout
rooms
Some participants will
stay in the main room
Those prompted: click
YES to both pop-up
screens to “move”

55. Small Group Discussion
0 Experience with comprehensive analysis 10
- Share your organization’s comprehensive analysis
process
(what works well and what can be improved)
- Point out the differences with the comprehensive
method presented
(4 objectives, steps, tools)
- What would you need to do tomorrow to make the
comprehensive analysis more effective

56. Large Group De-Briefing

57. Wrap-up

58. Next Steps
• End of session evaluation  certificate of attendance
• Follow up survey  we learn from you
Incident Analysis Learning Program
• Concise analysis – January 31, 2013
• Multi-incident analysis – February 21, 2013
• Recommendations management – March 7, 2013
• Follow-through and share what was learned – March 28,
2013

59. Resource slide
Learning Program – previous modules:
http://www.patientsafetyinstitute.ca/English/news/IncidentAnalysisLearningP
rogram/Pages/Session-Recordings-and-Documents.aspx
HQCA’s Systematic Systems Analysis
http://www.hqca.ca/assets/files/HQCA%20SSA%20Patient%20Safety%20Revi
ews%20FINAL%20June%202012.pdf
Incident Analysis Tools
http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnal
ysis/Pages/Tools.aspx

60. Mulţumesc
Thank You