System Evaluation of Reported Adverse Events (SERAE) Risk Mitigation and Quality Improvement

1. System Evaluation of Reported Adverse Events (SERAE) Risk Mitigation and Quality Improvement

3. “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 (8th leading cause of death) to 98,000 (4th leading cause of death) Americans die from preventable adverse events Cost: $17 to $29 billion US dollars Vehicle accidents 43,458; breast cancer 42,297; AIDS 16,516

4. PreventingAdverse Events Afterthe occurrence – Root Cause Analysis Sentinel events (SE)

5. Before the Occurrence – Failure Modes & Effects Analysis (FMEA) “FMEA is a team-based, systematic, proactive technique that is used to prevent process and product problems before they occur.” Joint Commission Can assess severity but not probability of occurrence

6. Similarities of FMEA and RCA • Aim to reduce harm to patients • Detail and labor intensive Difference between FMEA and RCA

7. An innovative approach Between RCA and FMEA System Evaluation of Reported Adverse Events (SERAE)

8. System Evaluation Reported Adverse Events (SERAE) SERAE is analysis ofadverse 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

9. 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…..

10. Advantages of conducting SERAE • Proactive • Timely • Less labor intensive • Meet standard • Less threatening to staff

11. Adverse event reported in other hospital/institution Flowchart of the SERAE NO Report no risk Possible risk YES Contact Department Manager//Unit-in-charge Review existing system / policy /compliance ID problem/ risk for improvement recommendation for improvement Refer CQI Report to Cluster Director (Q&RM) Report to CCE

12. Would similar AE be happening in our hospital? proximate causes Why did it happen? processes Why did that happen? Underlying causes systems Why did that happen? System Evaluation of Reported Adverse Events (SERAE)

13. 8 Key Questions to Ask in SERAE • Would similar adverse event (AE) be happening in our hospital? • Is there any SOP in your department? • How are the processes done? • Are there non-compliance and failure modes? • Evidence of similar AE • Other failure modes • What are the severity ratings of possible AE? • Which are the failure modes to address? • What are the corrective actions? • What improvement is planned for corrective actions? Written document Direct review on-site Review past record AIRS

14. Stratification of RAE for different approaches • Inappropriate / inadequate resources • Suboptimal system problem • SSPI single party • SSPII multiple parties

15. Stratification 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

16. Stratification of RAE • Suboptimal system problem SSPI - single party Example : Sharing of mortuary compartment leading to mixing up of dead body – involve mortuary

17. Suboptimal system problem SSPII - multiple parties Look Alike Drugs - Dormicum Vs Magnesium Sulphate (MgSO4 ) • Pitfalls: • Look alike drugs • Focus on clinical areas: • A&E • AICU • CCU • COD • DR • OTS • PAM • Involve doctors, pharmacy, nurses • Remove all ward stock of MgSO4 • Reinforce constant vigilance

18. 13 SERAE done in 2007 • Over Utilization of Mortuary • Percutaneous Coronary Intervention • Mixing of Intrathecal/Intravenous Administration of Cytotoxic Drug • Wrong site and dosing of Teletherapy • Look alike and sound alike medication error - Dormicum and Magnesium Sulphate • Retained tip of Close-Suction Tubing • Overdose of Protamine (Verbal Order) • Retention of swab in a patient’s cavity • Mixing up of disinfectants - OPA/Cidex and rinse water • Resuscitation in private ward • Fatal Fall Incident • Double BCG Vaccination • Wrong Labeling of Blood Specimens

19. 11 SERAE done in 2008 • Adverse Transfusion Reaction • Flying object in MRI • Missed radioactive material (C-137) in lab • Wrong corpse to families • Mix-up of Biopsy Specimen • Retained Detachable Light Bulb of Laryngoscope in patient • Lost of USP with patient data - Data Security • Post-PCI Death • Wrong Site Surgery • Wrong Radioactive Dye • Delayed resuscitation for a Collapsed Victim outside hospital

20. 8 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

21. 10 System Improvement through SERAE • Increased 22 numbers of cold chambers and share usage of mortuaries in HKWC • Removed all chemotherapy drugs ward stock • Reinforced ‘time-out’ for all operations and procedures • Removed all laryngoscope sets with detachable light bulbs • Provide individual insulated containers for transportation of blood/blood components to prevent condensation and mix-up

22. Ten 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

23. To get things done … we must be innovative

24. but…we must also be safe Thank You