Policy Making and Stakeholders

Root Cause Analysis Policy

POLICY

In the furtherance of achieving the goal of improvement in patient safety and its quality, it is the policy of Pikeville Medical Center (PMC) to make use of the Patient Safety Evaluation System (PSES) to collect, analyze, and submitting information about patient safety events to a Patient Safety Organization (PSO). The specific patient safety event for addressing the sentinel event of discharge of an infant to the wrong family should be scrutinized with quality surveillance for deeply probing into the actual or perceived issues within PMC facilities. The reporting of patient safety events, particularly the sentinel event of switching of newborns, is obligatory and encouraged.

The policy for reporting the patient safety event, particularly the selected sentinel event of discharge of the infant to the wrong family, should be reported to the hospital staff and facilities so that surveillance methods could be launched for prompt detection of the actual event and the relevant perceived issues. The processes and workflows of the concerned sentinel event should be improved so that human behavior should be modified and errors should be reduced for maximum patient safety (Strategic Radiology, n.a., p. 4).

DEFINITIONS

Sentinel event: A sentinel event is one in which patient safety is compromised, not necessarily due to natural reasons, including the patient’s illness, but may result in the following:

Death

Permanent harm

Severe, temporary harm

Severe, temporary harm: Severe, temporary harm is considered critical when its effects are life-threatening and last for a limited time. The severe, temporary harm caused by the sentinel event like the discharge of the wrong newborn to the family would cause severe psychological torment. The prolonged time for which the family would be under stress would cause serious medical conditions that would require a higher level of medical care.

Adverse event: An adverse event is one that resulted in causing harm to the patient.

Root cause analysis: An analysis is a comprehensive and systematic review of the problem that occurred within an organization (see Appendix). The framework is designed with the inclusion of 24 questions so that the assessment of the event must comprehensively take place.

PROCEDURES

Staff

The incident that involves a patient must be reported through online means so that the directly involved departments and staff should be contacted immediately (“Patient Safety Event Reporting,” n.a.). The urgency of nature should be determined at the spot as soon as the sentinel incident is reported, even if it is verbally conveyed to the supervisor. Sentinel Event Policy should be followed for sentinel events like a change of the newborn bay and discharging him to the wrong family. The responsibility then lies on the shoulders of the supervisor to communicate the event to the House Manager, Chief Nursing Officer (CNO), Assistant Vice President (VP) of Nursing, Unit’s Director, Chief Regulatory Officer (CRO), and Patient Safety Officer.

The patient safety event report should be completed immediately, preferably by the end of the shift, so that the importunity of the sentinel event must be addressed. All the pertinent data such as staff involved in handling the newborn information and the transference of the newborn from one section of the hospital to another till the newborn was delivered to his mother should be included in the report. The facts should be stated clearly and concisely to avoid any doubtful information. Personal opinions, inessential comments, and assumptions should abstain. According to the disclosure guidelines, facts about the patient safety event, physician notifications, patient interventions, patient’s response, and revelation should be included in the medical record and document. The reference of the patient safety report should not be mentioned in the patient’s medical record.

Additionally, it should be communicated to all staff members that patient safety event report is confidential and only for use within the organization. It should not be discussed in front of the hospital staff or victors for adhering to the hospital’s patient confidentiality policy. It must be well-perceived that patient safety event report is for the organization’s internal workings and must be privileged for PMC’s internal use.

Patient Safety Event Reporting System

The event reporting system would include accessing the hospital webpage, logging in, and clicking on the “report an event” tab; the required fields of the next web page asking about the incident that took place would be filled thoroughly, double-checking the entered information for any corrections, and clicking on “submit.”

After the incident is reported through the website and intranet, the follow-up procedures could be undertaken the next day immediately. If the weekend intervenes, Monday should be the next immediate day for taking an instant review of the issue. An email directly clicks on into the supervisor’s inbox, waiting to be reviewed by him so that instantaneous actions could be taken to avoid any possible patient safety event or its adverse events.

Procedure for supervisor analysis, 48 hours of notification

After the incident is reported, the supervisor must take action within 48 hours to follow up on the event as soon as possible to avoid traumatic consequences for the concerned family. It has been investigated that the in-hospital baby switches are seriously psychologically shocking for the parents and even hazardous for the newborn’s health as the baby would be breastfed by the wrong mother, leading to transmission of infection (Patient Safety Solutions, 2009).

The follow-up procedure encompasses clicking on the email to obtain patient safety event identification number, clicking on the hospital webpage and clicking on “follow-up,” clicking on the “evaluation” tab for reviewing for any possible accuracies, clocking on “move forward” for editing, and finally sending it to submit. The intranet should be logged out once a click on ‘close’ has been made and the patient safety event has been sent for evaluation to the concerned departments.

Role of Patient Safety Officer

The patient safety officer reviews all the documents to keep an eye on the progress of the sentinel event. The patient safety committee is formulated to analyze the event and find opportunities to remove the possible reasons that caused the event. The committee constitutes of Patient Safety Officer, Chief Medical Officer (or his designee), Chief Nursing Officer (or his designee), Chief Operating Officer (or his designee), AVP Laboratory or his designee), and other administrative personnel if applicable.