The document discusses a learning program on concise incident analysis, highlighting the method's significance, processes, and practical applications in healthcare settings. It outlines a case study of a medication incident that occurred in a home care context, analyzing factors contributing to the adverse event and proposing systematic recommendations for improvement. Emphasis is placed on interactive learning, knowledge sharing, and the incorporation of feedback to enhance patient safety and prevent recurrence of similar incidents.

1. Incident Analysis Learning Program - Module Five
Concise Analysis Method
January 31, 2013

2. Welcome
Tina Cullimore Sandi Kossey Erin Pollock Nadine Glenn Ioana Popescu

3. Learning Program
What was learned?
What can be done?
How and why?
What happened?
Multi-incident
Concise
Comprehensive

4. Learning Objectives
• The similarities and differences between a comprehensive
and concise individual incident analysis
• The main steps in conducting a concise analysis
• Give examples or scenarios of incidents where concise
analysis is recommended

5. Agenda
3-parts
• Knowledge expert + Q&A
• Practice leader + Q&A
• Facilitated discussion or Q&A

6. Introducing: WebEx
Be prepared to use:
- Raise Hand & Checkmark
- Chat & Q&A
- Pointer & Text
6
14-Mar-13 6

7. About You
0 Experience with [any] CONCISE analysis 10

8. Presentation
Carolyn Hoffman

9. Background and Features
 Need for a “concise” method
• Informal (mini-RCA)  Formal (NPSA, M&M)
 Consistent with the principles and methodology of
analysis
 Conscious and deliberate decision to focus on the:
• Agreed-upon facts
• Key contributing factors and findings
• Actions for improvement (if any)
• Evaluation

10. Concise and Comprehensive
Action Concise Comprehensive
Include person(s) with knowledge of IA, HF, solutions
development
Facilitated by an individual with input from patient,
local staff & physicians
Conducted by an inter-disciplinary medium to large ad
hoc group (includes also external experts / consultants)
facilitated by a knowledgeable individual.
Short Longer
Time taken for analysis (hours-days) (45-90 days)
Identifies contributing factors as well as remedial
action(s) taken (if any) and recommendations for
improvement
Reflects intent Incorporates all
Principles of Incident Analysis principles
Evaluation Component

11. Page 46
Canadian
Incident
Analysis
Framework

12. Case: Medication Incident
Setting:
Community hospital & busy home care services
Current process:
 hospital faxes referrals to fax line
 if 9-5, M-F, home care coordinator reviews faxes & accesses the
home care central record  schedule home care visits
 if outside business hours home care nursing staff periodically
check faxes  sorts by ongoing and new clients  referrals for
ongoing given to responsible nurse
 pharmacist dispense meds from drug stores in the community.
 some attending physicians at comm. hosp fax prescriptions to
patients’ drug store for ease of pickup
Incident
Client (discharged from hospital with meds) found in bathroom.
Moderate amount of bright red blood. Transfer to ED.

13. WHAT HAPPENED?

14. Case: What Happened
Based on the
• incident report
• a review of the home care record
• hospital chart
• referral form
…the facilitator responsible to conduct this concise analysis
started to draft a timeline of the incident.
Timeline confirmed and expanded by
• Interviews with the client, pharmacist and RNs,
• Examination of the drugs involved in the incident

15. Case: Timeline
Example
(p.113)

16. HOW AND WHY IT HAPPENED?

17. Analyze Information
• Use guiding questions to briefly explore all
categories (Appendix G, Page 89)
• Use some questions or develop incident specific questions to
informally discuss the incident with those involved and
external experts
• Ask
• What was this influenced by?
• What else affected the circumstances?
• Use constellation diagram
• Systemic approach
• Visual representation
• Linkages
• Summarize findings

18. Case: How and Why

19. Case: Findings
Work environment
• The lack of a standardized home care risk assessment tool or protocol
increased the likelihood that clients discharged from hospital back
to the community would not be accurately triaged to ensure appropriate
and timely home care services are provided.
Patient
• The deterioration in the client’s physical and cognitive abilities
increased the likelihood of a medication error in his self medication
management.
Care team and organization
• The lack of a formalized, system-wide and communicated Discharge
Medication Reconciliation process (including an updated Best Possible
Medication History) decreased the likelihood that the client would
receive the appropriate and timely support required for safe medication
management.

20. WHAT CAN BE DONE…?
WHAT CAN BE DONE TO REDUCE THE RISK OF
RECURRENCE AND MAKE CARE SAFER

21. Case: Recommended Actions

22. Case: Follow-through

23. WHAT WAS LEARNED?
The ultimate objective of analysis
Feedback
• To the organization: patient family, those involved in
the incident, the analysis team, etc
Feed-forward
• Externally to prevent similar incidents from
occurring in other organizations, systems, countries
• Informing the public and/or media

24. Questions?

25. Real-life Experience
Gordon Luy

26. Safety at Home: A Pan-Canadian Home Care
Safety Study, Root Cause Analysis Sub-Project
- Project #4 – Falls by Home Care Clients
(Canadian Patient Safety Institute)
Gordon Luy, BSW, MSW
Patient Safety Consultant
Winnipeg Regional Health Authority
Quality Improvement & Patient Safety Unit

27. Safety At Home Study
Led by Dr. G. Ross Baker of the Institute of Health Policy,
Management and Evaluation, at the University of Toronto.
A qualitative study to investigate the root causes and contributing
factors that lead to {Falls-; Medication-} related adverse events
suffered by patients in home care, and help to form
recommendations to prevent similar events in the future.
The study was conducted at three provincial sites:
Alberta Health Services - Edmonton Zone Home Living Portfolio.
Winnipeg Regional Health Authority
Community Care Access Centres (CCAC) of the Greater Toronto Area (GTA)

28. Winnipeg Regional Health Authority
Quality & Patient Safety Unit
 Part of the Research and Applied Learning
Division of the WRHA
 3 Units in division
 Health Information Services
 Research and Evaluation
 Quality Improvement & Patient Safety

29. WRHA Quality Improvement & Patient Safety Unit
• Under the Chief QIPS Officer
• Composed of 3 teams each under a regional
Director:
o Clinical Office of Patient Safety: 2 Analysts; and, 1
Auditor
o Quality Improvement Team: 7 Quality Managers; 2
Coordinators; and, 3 Analysts
o Patient Safety Team: 8 Patient Safety Consultants;
1 Patient Safety Pharmacist; and, 1 Education
Consultant

30. WRHA Patient Safety Consultant
A Patient Safety Consultant (PSC) works in collaboration with
healthcare sites/settings/program leaders and other members of
the Quality and Patient Safety Unit to facilitate the development,
implementation and maintenance of the quality and patient safety
strategy.
Through system safety reviews (Critical Incident Reviews),
PSCs assist staff and physicians throughout the Region to gain an
understanding of the complex systems in which people work for
potential healthcare system improvements.*
* The Regional Health Authorities Amendment And Manitoba Evidence Amendment Act (2005)

31. Safety At Home:
Sub-Project #4 – Falls by Home Care Clients
 Five specific Home Care cases were selected
from the Manitoba site (WRHA) for a detailed
review using the CPSI Concise Methodology.
 The review included interviewing caregivers,
managers, clients and their families regarding
events related to a fall which occurred during the
period of time that the client was receiving Home
Care.

32. CPSI Concise Analysis Methodology
I. Understand WHAT HAPPENED:
i. Information gathering (medical records; interviewing clients, case
coordinators and direct service providers (nurses, health care aides)
ii. Construct a a brief timeline.
II. Analyze information to identify contributing factors and the
relationships among them:
i. Systems theory and human factors
ii. Describe the incident and outcome
iii. Identify and define relationships between potential contributing
factors
iv. Formulate findings
III. (Develop and manage Recommended Actions)
The final report contains the facts, contributing factors, a brief context
analysis, and where applicable, recommended actions and a plan for
evaluation and dissemination.

33. I. Understand WHAT HAPPENED:
1. We reviewed the client’s medical record: (assessments; client
characteristics (e.g. co-morbidities), medications and changes; equipment;
professional consultation; process(es) of care delivery (e.g. history,
frequency and purpose of visits); circumstances of fall; etc.
2. We interviewed:
- Clients (and family): (recollection of event, factors (e.g. environment –
photos taken), services)
- Case coordinators: (organization, policies, care plan; roles, workload,
resources, training, communication, etc.)
- Direct service providers (nurses, health care aides): (roles,
workload, scheduling, resources, etc.)
3. We constructed a brief timeline (chronology) of event

34. Incident Analysis – Systems Theory
A system is described as the coming together
of parts, interconnections and purpose.*
Human Factors: how humans interact with the world
around them. Human error is viewed as a symptom of
broader issues within what may be a poorly designed
system, such as an adverse physical or organizational
environment.**
* Institute of Medicine. Crossing the Quality Chasm: A new health system for the
21st century. Washington, DC: The National Academy Press; 2001.
** Dekker S. The Field Guide to Human Error Investigations. Aldershot, UK: Ashgate
Publishing; 2002.

35. II. Incident Analysis
• Task (care/work process)
• Equipment
• Work environment
• Patient (client) characteristics
• Caregiver
• Care team (direct service providers and support
team)
• Organization (policies, culture, capacity-resources)

36. Constellation Map of Contributing Factors

37. Case Example
• Equipment: Motorized wheelchair; manual wheelchair;
hospital bed; transfer poles in bedroom and bathroom; bath
seat; Hoyer Lift and slings; Life line.
• Work environment: Customized private bungalow; guide
dog; client alone at times.
• Patient characteristics: Parkinson’s Disease; chronic
back pain and hip pain; physically compromised; alert &
oriented but at times has impaired judgment and memory
issues; quiet and slurred speech; functional hearing; wears
glasses.

38. Factors of Influence in Event
Equipment: Motorized wheelchair: client sits too far forward and does not use
the seatbelt.
Client: Lack of leg strength to push self
Environment: The client and family
back in the seat of the motorized
prefer that the client lives in the
wheelchair. Seating position increases the
residence as long as possible. While
risk for a fall. Motorized wheelchair is
cared for by extended family and
preferred for mobility over the manual
through Home Care much of the day,
wheelchair even though the seating
there are periods of time when the
position is safer in the manual wheelchair.
client is alone. Due to compromised
Risk for a fall is increased if the client falls
judgment and toileting issues, the
asleep in the wheelchair - tendency to fall
client may attempt to transfer when
asleep is exacerbated by medications.
assistance not available which has
Also, the client at times attempts to reach
led to falls in the past and increases
or ambulate without assistance present.
the risk for a fall.

39. Summary Statements/Findings
• The client is more at risk for a fall when using the motorized
wheelchair, than the manual wheelchair, due to the seating
position in the motorized wheelchair and consequent inability
to use the seat belt.
• Preference for using the motorized wheelchair at home
predisposes the client to this risk especially if the client falls
asleep while in the wheelchair or forgets that he/she in the
wheelchair.
• The tendency to fall asleep is exacerbated by medications
prescribed to address medical conditions.
• The Home Care services provided were maximized according
to the funding formula.

40. Report Format
• Date of Event
• Date Event was discovered
• Brief Description of event
• Date Event Analysis process was initiated
• Date Event Analysis process was completed
• Describe what Home Care Services received prior to the fall.
• Describe what Home Care Services received after the fall
• Describe the Client’s primary and secondary medical conditions.
• Does the Client live alone?
• The extent of harm as assessed 24 hours post event.
• Outcome of event
• Additional Issues
• Medications and how related to event
• Chronology
• Constellation Map
• Identification of factors that contributed to the occurrence of this
event
• Summary Statement

41. Reflection
• CPSI Concise Methodology
– Very similar to the what we have been using in the
region to review some Critical Incidents (falls and
pressure ulcers).
– Is a useful framework for the review of an adverse
event of limited harm to the patient (client):
• Conceptualizing;
• Planning;
• Conducting; and
• Documenting.

42. Questions?

43. Learn from Each Other

44. Options
1. Learn from each other
• Suggested topics
o Do you use concise now? For what cases?
o Is it helpful? How long it takes? How is it done?
o How did you get started? How did you spread it?
2. Q&A with the 2 presenters

45. Breakout Session
Some participants will Some participants will
stay in the main “move” to breakout
room rooms
- No phone next to
your name
- Say no when
invited to breakout

46. Large Group De-Briefing
Highlights from small group discussion
Nuggets from the Q&A

47. Recap and Next Steps
End of session evaluation; Follow up survey
• Follow-through and share
what was learned
March 28, 2013
• Recommendations
management
March 7, 2013
• Multi-incident analysis
February 21, 2013

48. Resources
Learning Program – previous modules:
http://www.patientsafetyinstitute.ca/English/news/Inci
dentAnalysisLearningProgram/Pages/Session-
Recordings-and-Documents.aspx
National Health System – UK
• Three Levels of RCA Investigation – Guidance
• Example concise RCA investigation reports
Incident Analysis Tools
http://www.patientsafetyinstitute.ca/English/toolsReso
urces/IncidentAnalysis/Pages/Tools.aspx

49. Mulţumesc
Thank You