System Evaluation of Reported Adverse Events (SERAE) Risk Mitigation and Quality Improvement
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Patient Safety and Risk Management System Evaluation System Evaluation of Reported Adverse Events of Reported Adverse Events (SERAE) (SERAE) Risk Mitigation and Quality Risk Mitigation and Quality Improvement Improvement
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System Evaluation of Reported Adverse Events (SERAE) Risk Mitigation and Quality Improvement. “To Err is Human” – IOM Report - 1999. Injuries caused by medical management: 974,400 to 1,243,200 annually - 53% to 58% preventable. 44,000 (8 th leading cause of death) to - PowerPoint PPT Presentation
Transcript of System Evaluation of Reported Adverse Events (SERAE) Risk Mitigation and Quality Improvement
Patient Safety and Risk Management
System Evaluation System Evaluation
of Reported Adverse Eventsof Reported Adverse Events
(SERAE) (SERAE)
Risk Mitigation and Quality ImprovementRisk Mitigation and Quality Improvement
Patient Safety and Risk Management2
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“To Err is Human” – IOM Report - 1999
Injuries caused by medical management:
974,400 to 1,243,200 annually
- 53% to 58% preventable
Cost: $17 to $29 billion US dollars
Vehicle accidents 43,458; breast cancer 42,297; AIDS 16,516
44,000 (8th leading cause of death) to98,000 (4th leading cause of death) Americans die from preventable adverse events
Patient Safety and Risk Management4
After the occurrence –
Root Cause Analysis
Preventing Adverse Events
Sentinel events (SE)
Patient Safety and Risk Management5
Before the Occurrence – Failure Modes & Effects Analysis (FMEA)
Can assess severity but not probability of occurrence
“FMEA is a team-based, systematic, proactive technique that is used to prevent process and product problems before they occur.”
Joint Commission
Patient Safety and Risk Management6
Difference between FMEA and RCA
Characteristics FMEA RCA
Analysis Proactive Reactive
Questions Hypothetical Actual
Approach Prospective retrospective
Similarities of FMEA and RCA• Aim to reduce harm to patients
• Detail and labor intensive
Patient Safety and Risk Management7
An innovative approach
Between RCA and FMEA
System Evaluation of Reported Adverse Events System Evaluation of Reported Adverse Events
(SERAE)(SERAE)
Patient Safety and Risk Management8
System Evaluation System Evaluation Reported Adverse Events (SERAE)Reported Adverse Events (SERAE)
SERAE is analysis of adverse events
occurred and reported in other hospitals.
a systematic, proactive technique that is
used to prevent process and system
problems before they occur in OUR hospital
Patient Safety and Risk Management9
Why SERAE?
•Actual occurrence has transpired.•Actual data on interaction of failures can be obtained
•Actual reference point and not just purely theoretical exercise
•As in RCA, a “learn and prevent” mindset can prevail
The boss (CCE) likes to know anyway…..
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Advantages of conducting SERAE
• Proactive
• Timely
• Less labor intensive
• Meet standard
• Less threatening to staff
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Flowchart of Flowchart of the SERAEthe SERAE
Adverse event reported in other
hospital/institution
Possible risk
Contact Department Manager//Unit-in-charge
Review existing system / policy /compliance
ID problem/ risk for improvement
recommendation for improvement
Report to Cluster Director (Q&RM)
Report to CCE
NO
YES
Refer CQI
Report no risk
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System Evaluation of Reported Adverse EventsSystem Evaluation of Reported Adverse Events
(SERAE)(SERAE)
Would similar AE be happening in our hospital?
Why did it happen?
Why did that happen?
Why did that happen?
proximate causes
processes
systems
Underlying
causes
Patient Safety and Risk Management13
1. Would similar adverse event (AE) be happening in our
hospital?
2. Is there any SOP in your department?
3. How are the processes done?
4. Are there non-compliance and failure modes?
Evidence of similar AE
Other failure modes
5. What are the severity ratings of possible AE?
6. Which are the failure modes to address?
7. What are the corrective actions?
8. What improvement is planned for corrective actions?
8 Key Questions to Ask in SERAE8 Key Questions to Ask in SERAE
Review past recordAIRS
Written document
Direct review on-site
Patient Safety and Risk Management14
Stratification of RAE for different Stratification of RAE for different approaches approaches
• Inappropriate / inadequate resources
• Suboptimal system problem
SSPI single party
SSPII multiple parties
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Stratification of RAEStratification of RAE
• Inappropriate / inadequate resources
Usually need simple corrective action
Example
Retention of laryngoscope light bulb in
patient’s airway :
Cause – detachable light bulb on blade
Remedy – change to fiber-optic laryngoscope
Patient Safety and Risk Management16
Stratification of RAEStratification of RAE
•Suboptimal system problem
SSPI - single partyExample : Sharing of mortuary compartment leading
to mixing up of dead body – involve mortuary
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Look Alike Drugs - Look Alike Drugs - Dormicum Vs Magnesium Sulphate (MgSODormicum Vs Magnesium Sulphate (MgSO4 4 ))
Pitfalls:Look alike drugs
Focus on clinical areas:A&EAICUCCUCODDROTSPAM
Involve doctors, pharmacy, nursesRemove all ward stock of MgSO4 Reinforce constant vigilance
Suboptimal system problemSSPII - multiple parties
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13 SERAE done in 200713 SERAE done in 2007Over Utilization of MortuaryPercutaneous Coronary InterventionMixing of Intrathecal/Intravenous Administration of Cytotoxic DrugWrong site and dosing of TeletherapyLook alike and sound alike medication error - Dormicum and Magnesium SulphateRetained tip of Close-Suction TubingOverdose of Protamine (Verbal Order)Retention of swab in a patient’s cavityMixing up of disinfectants - OPA/Cidex and rinse waterResuscitation in private wardFatal Fall IncidentDouble BCG VaccinationWrong Labeling of Blood Specimens
Patient Safety and Risk Management19
11 SERAE done in 200811 SERAE done in 2008Adverse Transfusion ReactionFlying object in MRI Missed radioactive material (C-137) in labWrong corpse to familiesMix-up of Biopsy SpecimenRetained Detachable Light Bulb of Laryngoscope in patientLost of USP with patient data - Data SecurityPost-PCI DeathWrong Site SurgeryWrong Radioactive DyeDelayed resuscitation for a Collapsed Victim outside hospital
Patient Safety and Risk Management20
8 SERAE done in 20098 SERAE done in 2009
Missing baby corpse in mortuary
An Eye nurse performed outside work without seeking approval
Wrong identification of 2 newborns
Expired BCG Vaccine was administered to 5 newborns
Oral syrup Morphine was injected to a patient
Penicillin was administered to a wrong neonates
Shortage of specimen bottle in GOPCs
Double doses of Influenza vaccine was administered to an elderly
Patient Safety and Risk Management21
10 System Improvement through SERAE10 System Improvement through SERAE
Increased 22 numbers of cold chambers and share usage of mortuaries in HKWCRemoved all chemotherapy drugs ward stockReinforced ‘time-out’ for all operations and proceduresRemoved all laryngoscope sets with detachable light bulbs Provide individual insulated containers for transportation of blood/blood components to prevent condensation and mix-up
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Ten key Changes - continuedTen key Changes - continued
Reinforced proper record and handling of abortus / fetus / stillbirth
Revised the form on “Request for Human Tissue Disposal”
Installed 16 small cold chambers for babies / fetus
Reinforced newborn identification by encouraging rooming-in
Minimize “ward dispensing practice” - limit ward stock
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To get things done … we must be innovative
Patient Safety and Risk Management24
but…we must
also be safe
Thank You
