Many hospitals are still struggling with their root cause analyses of serious adverse events. One of the problems is just getting started promptly. One of the keys to good incident investigation is obtaining all the factual evidence as soon as possible. Particularly when it comes to interviewing witnesses, it is important to remember that memory of the event becomes less clear with passage of time and those memories may even be changed by other events, conversations, etc. It is extremely important that we understand how the participants in the incident perceived the unfolding situation and events as they occurred, rather than reinterpreting them after knowledge that the outcome was adverse.
Therefore, each hospital should have a Serious Incident Response policy and checklist to help guide them in their response to a serious incident. A link to a sample serious incident response checklist is at the end of this tip of the week.
Obviously, the individual assigned responsibility for each task may vary from organization to organization. But having the task listed on a checklist and and individual designated helps everyone remember what needs to be done.
The “serious incident” might meet the Joint Commission definition of a Sentinel Event or the state health department definition of a serious reportable event but you should also consider even near-misses as meeting the definition if there was potential for a serious adverse patient outcome. On receiving the incident report, the designated individual (usually a risk manager) should immediately discuss the incident with the medical director, director of nursing and director of quality improvement to decide whether the Serious Incident Investigation Team/RCA Team should be convened. The risk manager (or other designated person) should contact the supervisor of the area where the incident occurred to ensure that all potential witnesses are identified and then schedule a meeting of the Team as soon as possible (usually within one day). In those cases where a witness will be unavailable to be interviewed in person, arrangements can usually be made for that person to be interviewed by phone.
The chart of the patient should be secured and working copies made for use by the Team. Similarly, any equipment or devices involved should be sequestered. That is to ensure that the equipment is available for the investigation and also to ensure that any potentially faulty equipment is not used for another patient.
We believe that the patient and/or family should be notified early that errors may have occurred and that the incident is being investigated. We’ve long been believers in being very forthright with patients/families and telling them when there were mistakes made in their care. Subsequent research and other experience certainly seems to bear out that such an approach and an apology are important when mistakes or errors did impact on the outcome. The details and the apology, of course, cannot be given until the RCA is complete and all contributing factors known. However, our experience is that patients and families appreciate candor and should be told that an investigation is ongoing and that they will be made aware at some point of at least the general outcome of that investigation. It should be made clear to them that the investigation is being done to help ensure that similar events do not occur in the future. The individual who speaks to the patient or family should usually be the one with the best pre-existing rapport. That is usually the attending physician but may under some circumstances be someone else in the organization. If it is awkward for the attending physician to speak to the family, then the medical director is an appropriate individual to speak to them.
Most of the other items in the check list are self-explanatory (mostly notification to various agencies and bodies of the incident occurrence). Some state Department of Health offices require notification of certain events within 24 hours. Even if that is not a formal requirement, a good general rule is to notify them of any event that is likely to attract press attention. That way the state department is not taken by surprise if an inquiry is made and they are able to respond that they are aware of the incident and the ongoing investigation.
The last item is very important and often overlooked. Caregivers undergo a variety of deep emotions when one of their patients is harmed, particularly when they feel they may have contributed in some way to that adverse outcome. So each organization should have some mechanism for providing needed support and assistance to any physicians, nurses, pharmacists, etc. that may have been directly involved in the incident or had been actively involved in the care of the patient.
See a sample Serious Incident Response Checklist.