To Err is Human: Incident Management and Open Disclosure
When Jonathan and Timothy were born, I vividly recall looking at them in sheer amazement that the human body could come together so perfectly. As we sadly know, things can go wrong in the delicate process of growing a human. In some respects, the same is true of providing care to people, particularly groups of people, with complex needs and individual preferences. We should recognise and celebrate how often things go ‘right’, as well as identifying and seeking to learn from when they go ‘wrong’.
This article looks at how we can use a negative or adverse event to provide better care and services. The new aged care standards require providers to have incident management systems and processes in place. This includes appropriate identification and response to incidents and near misses; adequate record keeping; evidence of investigation and continuous improvement, ideally with consumer participation; and the practice of open disclosure.
Identification and response
The landmark ‘To Err is Human’ report by the Institute of Medicine (2000) estimated that that 98,000 people in the US die each year from medical errors that occur in hospitals. In Australia, the Grattan Institute (2018) estimates that about one in every nine patients who attend hospital experience a complication. This rises to one in four if they stay overnight. These complications include falls, pressure injuries, infections and medication errors – all of which are also frequent in aged care settings. While we currently don’t have published data for older people living in residential services, we could expect a similar risk of harm. Providers should work closely with staff to help them understand that accidents happen, foster a ‘no blame’ culture and encourage early identification and reporting of incidents and near misses.
Once an incident or near miss occurs, the following should happen:
· Take immediate action to ensure the safety and wellbeing of the people involved and provide any first aid.
· Notify appropriate people of event as per local policy or procedure. This will often include the Registered Nurse or Medical Officer, Service Manager and the person responsible (e.g. next of kin, guardian or carer). Providers should have a clear escalation and communication process for reporting incidents and near misses.
· Multidisciplinary review of the individual’s care plan. Depending on the type, severity and frequency of the incident or near miss, a family conference should be triggered to provide further information about the event; discuss and agree strategies to reduce the risk of reoccurrence while also preserving the person’s independence and quality of life.
Reporting and investigation
Once appropriate immediate action has been taken, the incident or near miss should be documented in the incident management system and progress notes. The incident management system supports contemporaneous record-keeping; the monitoring and reporting of incidents and action taken; and the identification of any hot spots or trends. It is also a valuable educational tool – deidentified case studies can be used to good effect at clinical governance meetings and forums to engage staff in discussions about improving the safety and quality of care.
The events and circumstances surrounding the incident or near miss should then be reviewed and investigated. Depending on the nature and severity, it may be important that this investigation is led or overseen by an independent person or team. There are a variety of methodologies and techniques available to support thorough and high-quality incident investigation. These include Root Cause Analysis as detailed in the NSW Health Incident Management Policy (2014), the London Protocol, the Five Whys, and Failure Modes and Effects Analysis (amongst others).
In my humble opinion, good incident investigation comes down to the following:
1. Assembling the right team with the knowledge, skills and expertise to independently review the incident.
2. Developing a comprehensive timeline that sets out the circumstances and events leading up to the incident.
3. Reviewing any policies or procedures and co-creating a process or service map to flesh out what ‘should’ happen and then interviewing people involved to determine what did/ does happen.
4. Ability to have open and honest conversations with the people involved.
5. Where appropriate, observation of the environment, process or systems to assess work flow, interactions and potential contributing factors.
6. Lead investigator with facilitation and analysis skills to support the team to take a systems approach to identifying the underlying causes of the incident and potential solutions. The Swiss Cheese model is useful to help the team consider the range of controls designed to reduce the risk of harm and identify the ‘holes’ in these controls that resulted in the event occurring.
The investigation report with recommendations is just the start of the long journey towards implementing change to improve the safety and quality of care. It’s important you reserve energy and resources for this important process, for without real and sustainable change, there will be little impact on risk and incident rates. Stay tuned for the next article zooming in on continuous improvement!
Once an incident or near miss has occurred, open disclosure should follow. This means that the person and their nominated representative/ family are openly and honestly informed about what happened as quickly as possible; with the immediate actions taken and next steps explained to them. It should also include an apology and acknowledgement that something went wrong. The nominated representative/ family should be given the opportunity to be involved in the ‘next steps’ to the extent that they wish. This may include supporting them to participate on the investigation/ review team or making suggestions for how care and services could be improved.
My day care frequently calls and leaves messages to advise of events that have transpired throughout the day. Then, at pick up time, I am given a form that outlines what happened, what the staff were doing at the time of the accident (including the staff:child ratio) and asked to acknowledge that I have had the incident explained to me. I am always very reassured by this process, the documentation and a phone call/ message that starts with “it’s nothing serious and Jonathan and Timothy are ok”!
Despite the range of initiatives in health care designed to reduce complications and improve patient safety, the incident rate in hospitals does not appear to be declining (Grattan, 2018). What does this tell us? That there is only so much we can do after things go wrong. I believe a switch to investing in better understanding why things go right is the answer.
What has your experience of incident management been? How do staff feel about Open Disclosure? And how might we develop an approach or methodology to explore the critical success factors of an otherwise ‘uneventful’ day?
Aged Care Quality and Safety Commission. Aged Care Quality Standards, Standards 2, 3, 6 and 8.
Aged Care Quality and Safety Commission (2019). Open Disclosure Framework and Guidance. Available at: https://www.agedcarequality.gov.au/resources/open-disclosure.
The Grattan Institute (2018). All complications should count: Using our data to make hospitals safer. Available at: https://grattan.edu.au/wp-content/uploads/2018/02/897-All-complications-should-count.pdf
Imperial College London, Systems Analysis of Clinical Incidents: The London Protocol. Available at: https://www.imperial.ac.uk/media/imperial-college/medicine/surgery-cancer/pstrc/londonprotocol_e.pdf.
Institute of Medicine (2000). To Err is Human: Building a Safer Quality System. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25077248.
NSW Health (2014). Incident Management Policy PD2014_004. Available at: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_004.pdf.
The Royal College of Obstetricians and Gynaecologists (2019). The Swiss Cheese Model. Available at: https://elearning.rcog.org.uk//human-factors/clinical-error/swiss-cheese-model.