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 Learning From Adverse Events

Root-cause analysis and a four-step action plan can improve performance and quality of care following a serious patient incident.

 

Scenario: A resident falls and sustains a fracture. The resident has a recent history of falls. The certified nurse assistant reports the tab alarm was not in place, as was required by the care plan.

Incidents should not happen; deficient practices should not happen; but they do. Preventing the occurrence of adverse events is ideal.  Once an event occurs, the facility staff have the ability to react rapidly using a sound performance improvement (PI) framework.
 
Such a response demonstrates the facility’s ability to self-identify problems and self-correct a flawed system.

Legal Ramifications

There are regulatory implications associated with adverse events. The intent of the Quality Assurance and Assessment F-Tag is to require the facility to self-identify and self-correct breakdown in systems that have resulted in actual or potential for poor quality of care.
 
In addition, many serious events also meet the criteria for “self-reporting” to the state regulatory agency. Based on these state-specific guidelines, the center reports an incident; the state investigates, agrees there was an incident, and then fines the center.
 
These same types of events can result in a community complaint to the state agency, which in turn can result in citations and/or civil money penalties for the center. 
 
An appropriate response will reduce the risk of adverse outcomes for other residents and may help mitigate the regulatory and financial impact. The facility can embrace a serious event as an opportunity to evaluate systems and correct practices as indicated.
 
The purpose of this article is to provide a practical framework to guide a facility response to a serious issue.
 

Improving Performance

The following events are likely to lead to an actual harm citation or a potential for high severity and scope: sentinel events, such as dehydration, fecal impaction, development of a pressure ulcer in a low-risk individual, and serious incidents, such as abuse, fall with injury, serious medication error, lack of identification or response to a change of condition, and avoidable pressure ulcers.

What defines an appropriate and prompt response to a serious event? Too often, there is a “hit or miss” approach to addressing the issue at hand. The Centers for Medicare & Medicaid Services has provided a framework to direct the facility in using a systematic performance improvement approach. Known as the traditional Plan of Correction (POC), it provides a step-by-step framework for the center’s action plan.

After determining root cause(s) for the adverse event, the facility then implements the four steps of the POC:  corrective actions, identification of others at risk from same deficient practice, systemic changes, and monitoring.
 


 
Performing a root-cause analysis and addressing the cause or causes with the four-step action plan is, in essence, a dynamic application of PI. It is recommended that the facility’s quality assurance committee promptly review the root-cause analysis and four-step action plan.
 
This element provides evidence and validation that the facility is self-identifying and self-correcting under the PI process.
 
In addition, the facility’s medical director should review any new action plans. Medical director involvement is particularly important if the facility has any concerns the issue may represent a substandard quality-of-care situation. Facility leadership needs to remain aware of the status of current action plans and ensure that trends are identified through ongoing monitoring.
 
This process requires disciplined focus and leadership to mobilize a team to execute the root-cause analysis and the four-step action plan. The facility should maintain an organized tracking and documentation process as evidence for completing the course of action.
 

Evidence Of Effectiveness

An informal retrospective review of the results of standard, self-reported, and complaint surveys for 58 facilities over a one-year period found that in at least 15 instances, surveyors cited the facility at a lower severity and scope or chose not to cite at all after review of a facility’s four-step action plan response.
 
In a number of these situations, the surveyors commented about how impressed they were with the facility’s organized and thorough effort. There was also a significant correlation between high severity and scope citations in situations where the facility responded to an event with an inadequate root-cause analysis or an incomplete four-step action plan.
 
Traditionally, nursing facilities employ the elements of a POC only in response to formal survey findings. But facilities will benefit by reacting rapidly to a serious situation as if they were already cited. Proactively embracing the discipline of a four-step action plan when a serious event occurs is good clinical practice. This approach assists the facility in identifying a system breakdown, correcting it, and preventing other residents from being harmed by a similar practice.
 
The added benefit of the four-step action plan is the potential reduction in severity and scope or avoiding a citation altogether. 
 
Kathy Owens, RN, MSN, is vice president clinical operations and Donna Kelsey, NHA, MS, is senior vice president for the West Region, Health Services Division of Kindred Healthcare, in South Jordan, Utah. Owens can be reached at (801) 302-0058 or Kathy.owens@kindredhealthcare.com. Kelsey can be reached at (801) 302-0061 or Donna.kelsey@kindredhealthcare.com.
 
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