|Receipt of Report
How report was received:
- Hotline: Enter event report via the institution's event reporting system.
- Online: Review and prioritize events.
- Complaint/Grievance: Gather facts, and refer to patient/guest relations or the appropriate department/individual.
|Assess and Inform
- Ensure the patient is stable, and provide emotional support to the patient/family.
- Assess event for potential harm based on report/cursory electronic medical record review.
- Report any adverse event to the appropriate professional responsible for patient safety events. Activate Care for the Caregiver program and provide emotional support for caregivers and staff.
- Secure the event location (i.e., patient room or procedural area).
- Do not move, turn off, change equipment settings in:
- Patient room/procedural area – do not allow anyone in the area.
- All equipment and devices.
- All disposables (e.g., medication vials, IV bags, catheters.
- Contact clinical or biomedical engineering for assistance.
- Obtain all records: medical record, departmental worksheets, logs (e.g., transports), and schedules (e.g., OR, on-call).
- Identify all individuals involved in the event; determine via medical record review and interviews.
- Note any evidence of additions, corrections, or alterations in the medical record (contact IT to assist with EMR).
- Obtain all monitoring strips/records.
- Secure record of pages via operator or tracking mechanism.
- Secure photos/video recordings (OR/procedural) and/or security monitoring tape.
|Initial Key Communications
- Consider additional care provider referrals to Employee Assistance Program (EAP) and/or peer-support program.
- Prepare strategy for ongoing communication with key stakeholders and patient/family.
- Identify a patient/family liaison.
- Advise care providers on appropriate medical record documentation post event.
- Initiate process to hold hospital and professional fee billing.
- Notify appropriate individuals of the event (e.g., claims management, legal counsel, any liability carrier that might be involved).
- Assist legal counsel in gathering facts/information, as requested.
- Notify residency program directors, as appropriate.
- Contact the unit/program director of each employee to be interviewed.
- Schedule in-person interviews of key staff.
- Determine best physical setting and arrangement for interview.
- Prepare interview strategy, questions, and materials based on document review and event review handbook.
- Outline the subject areas to be addressed in logical sequence.
- Compose questions for each subject area.
- Collect medical records and other documents to establish timeline of events.
- Consider additional care provider referrals to EAP and/or peer-support program.
- Provide interviewees with contact information of interviewer.
EVENT INVESTIGATION AND ANALYSIS
|Steps for Investigation and Analysis
- Identify any potential issues for peer review or other accountability review in accordance with just culture principles.
- Develop investigation strategy.
- Use the following as guidance: Joint Commission's National Patient Safety Goals; National Quality Forum's Serious Reportable Events; or Centers fpr Medicare & Medicaid Services' "never" events.
- Identify organizational policies and procedures that apply to the event to determine whether they:
- Were followed, and/or
- Are in need of revision.
- Flow chart the process, if applicable.
- Conduct a literature review, if applicable.
- Enter all information in the hospital event reporting system.
- Obtain peer review, as appropriate.
- Keep leadership up-to-date on the process.
- Continue to monitor patient/family status and needs.
- Maintain contact with patient advocate/liaison.
|Concluding the Investigation
- Conduct consensus meeting with leadership and appropriate providers to review findings and determine next steps.
- Meet with malpractice insurer(s) to review findings.
- Implement changes to process, procedures and policies, as appropriate.
- Monitor changes to ensure results.
- In the final step, appropriate personnel will:
- Meet with patient/family to review findings, present resulting actions to prevent future recurrences of similar events.
- Determine if it is appropriate to continue to withhold some or all claims to third parties and bills to the patient.
- Offer to discuss financial restitution to the patient / family, if appropriate.