CSI Stanly
Clinical and Customer Service Investigation using Root Cause Analysis
Case examples of the past 18 months
• Staffs (both hospital & medical staff) are comfortable referring and participating in cases for evaluation. RCA has become another tool in the process improvement tool box. The use of RCA has been in a non punitive environment. Improvement Opportunities have varied from case to case. Examples from the past 18 months of case reviewed by Quality Council:
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Case 1: Respiratory Arrest in the immediate post-op period of care Improvements: (1) Standing order set changed from Phenergan 25mg to Phenergan 12.5mg IVP in the immediate post-op period. (2) Mandatory education on HealthStream for licensed nursing staff related to Phenergan and Zofran. Over 98% of staff completed the education. (3) Handoff check sheet from PACU nurse to receiving nurse on unit changed. Hand off continues to be face to face. Case 2: Stroke Alert not paged correctly Stroke Alert care performed correctly; however by not paging Alert, staff outside the Emergency Department (ED) was not informed. ED staff was aware that ED physician & neurologist were already in the ED awaiting the arrival of the patient (a 49year old physician) on staff. Crowd control became an issue without the House Supervisor involvement. Improvement: Re-education was provided for ED staff on Stroke Alert procedure and protocols. Case 3: Delayed diagnosis of subdural bleed in ED Improvements: (1) Level of Consciousness discrepancies between EMS documentation vs. nursing and physician documentation at arrival; follow up by Nurse Manager with staff and EMS. (2) Implemented neurochecks (with GCS) for falls; policy & procedure development and education by Nurse Manager (3) Late physician documentation referred to Chief of Service for follow up. (4) No documentation by hospitalist referred to Hospitalist Director (4) Charge Nurse handoff in ED, follow up by Nurse Manager
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• Case 4: Delayed diagnosis of subdural bleed in ED • Improvements: (1) Level of Consciousness discrepancies between EMS documentation vs. nursing and physician documentation at arrival; follow up by Nurse Manager with staff and EMS. (2) Implemented neurochecks (with GCS) for falls; policy & procedure development and education by Nurse Manager (3) Late physician documentation referred to Chief of Service for follow up. (4) No documentation by hospitalist referred to Hospitalist Director (4) Charge Nurse handoff in ED, follow up by Nurse Manager
• Case 5 • Patient discharged from ED and returned to ED in code <12 hours • Care and treatment appeared to be appropriate. Only opportunity noted was related to atrial fib not addressed by ED physician in ED record. • Improvement: Chief of Service provided education to physician regarding addressing abnormal testing results in patient’s record. • Case 6 • Radiology discrepancy reporting not handled correctly • Initial interpretation by NightHawk was negative. Over read by staff radiologist noted a pulmonary embolus. Report called to ED per radiologist. Patient was in Observation on a medical surgical nursing unit (not in ED) and was discharged without treatment. • Improvement: (1) Radiologist to document in record who receives report (2) Re-education with ED staff on handling of critical value reports when patient is no longer in the ED
• Case 7 • Patient with Abdominal Pain not handled expediently per family (customer service issue) • Patient admitted from ED with abdominal pain and negative work up except for elevated WBC (white count). Daughter irate that patient had not been seen early the next day by hospitalist. The hospitalist viewed patient as low priority and planned to see him last or late in the day. GB ultrasound ordered and CT scan repeated in 24hours with interval development of moderate GB distension. Patient had GB removed next evening. • Improvements: Better, more timely communication discussed with hospitalist. Unfortunately, daughter continued to believe that patient “would have died without her intervention.”
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Case 8 Patient discharged from ED and returned to ED in code <12 hours Care and treatment appeared to be appropriate. Only opportunity noted was related to atrial fib not addressed by ED physician in ED record. Improvement: Chief of Service provided education to physician regarding addressing abnormal testing results in patient’s record. Case 9 Radiology discrepancy reporting not handled correctly Initial interpretation by NightHawk was negative. Over read by staff radiologist noted a pulmonary embolus. Report called to ED per radiologist. Patient was in Observation on a medical surgical nursing unit (not in ED) and was discharged without treatment. Improvement: (1) Radiologist to document in record who receives report (2) Re-education with ED staff on handling of critical value reports when patient is no longer in the ED
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• Case 10 • Verbal orders resulting in medication error (omission) • Consulting pulmonologist in ICU calls pharmacy and orders stat IV antibiotics (no continuing orders). The attending physician who is also in the ICU writes the continuing orders for the same antibiotics. The pharmacists enter into eMAR only the verbal orders received. Faxed orders not received in pharmacy. • Improvements: (1) Re-education to physicians to avoid verbal orders, especially if present on the unit with the patient. (1) Re-education with pharmacy and nursing regarding medication process and validation of orders.
• Case 11 • Patient admission and death within 24 hours • Patient admitted from ED to the medical/surgical unit at 7p with moderately severe pancreatitis with at least parenchymal necrosis per CT scan. Patient codes and dies the next day. • Improvements: Case reviewed by entire hospitalist group. Journal articles reviewed and discussed on pancreatic necrosis and use of antibiotics. Physicians also discovered that they should request radiologist to estimate amount of necrotic involvement for appropriate treatment and antibiotic use.
Verbal Orders
• • • Case 12 Verbal orders resulting in medication error (omission) 47 year old diabetic admitted to medical/surgical floor with vomiting and abdominal pain. Nursing staff unable to control patient’s pain the next day and escalate care to a rapid response team call for patient’s complaint of chest pain. Hospitalist arrives to evaluate patient, orders transfer to telemetry unit and initiates an IV order change from NS toD5NS. Patient is on an escalating algorithm for insulin dosage based on blood sugar results. Patient refuses full insulin dosage twice thinking he would get his usual bedtime insulin that he had discussed with the hospitalist. He was unaware of the change in IV fluids. Hospitalist says she gave verbal orders for the night time insulin, but acknowledged there was no repeat of her order given. All the other orders were written. Patient’s blood sugar the next morning was 811. Improvements: (1) Re-education with physicians to avoid verbal orders especially when present on the unit (2) Discussion with physicians and staff on patient and family involvement in plan of care. RCA was reviewed with patient’s wife at her request.
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Global Outcomes
Mortality Rate
3 2.5 2 1.5 1 0.5 0
Rate
Series1
20
20
20
20
20
20
Fiscal Year
20
09
YT D
03
04
05
06
07
08
Joint Commission Strategic Surveillance System “S3”
• Stanly Regional’s most recent score is 76 based on a rolling 3 years of data. This compares favorably with the North Carolina average of 140 and National average of 141 for the same time period.
Sharing Knowledge:
• Stanly Regional invites participants in the actual events to participate in the development of the flow charting of the event and opportunities for improvement ideas. The RCA charts can often be found in staff lounges and used at staff meetings for additional staff education. Educational events, such as the Phenergan RCA, may be mandatory for staff (this one for licensed nursing staff). Exposure of Board Members to this level of analysis, to our knowledge, is also unusual. Many Boards are unaware of the type, number, and/or frequency of the events in their institutions.