Imagine a patient, stable preoperatively and for whom you expected an uncomplicated recovery, suddenly experiencing cardiac arrest upon transfer from the OR to the recovery area. What could have gone wrong? What did you miss? This fictional scenario may not lie far from reality in any medical center in the United States. To Err is Human: Building a Safer Health System, an Institute of Medicine report in 1999, exhorted hospitals to study adverse events and the systems that allow their occurrence. Prior to its publication and in concert with standards of the Joint Commission on Accreditation of Healthcare Organizations, Dartmouth-Hitchcock Medical Center (DHMC) sought to develop a blame-free methodology to identify adverse events. The goal was to discover how these events were emblematic of system inadequacies and to implement risk reduction strategies to prevent future occurrences. The process was begun in 1998 and is available to all the center’s clinical staff and faculty.
A Careful Review
The significant adverse event review process is directed by an interdisciplinary committee known as SEARCHES (Significant Adverse Event and Root Cause Analysis of Hospital Systems). Chaired by the executive medical director, the committee includes four physicians from neurosurgery, plastic surgery, hematology and anesthesia, four clinical nurse specialists from psychiatry, oncology, critical care and pediatrics, a pharmacist, a risk manager and a quality adviser.
Adverse events are generally reported to either the risk management or clinical quality department. If merited, the quality adviser convenes a review team, a subgroup of the SEARCHES Committee. A full root cause analysis (RCA) is conducted for any adverse event that may have contributed to or resulted in permanent patient harm or death, unrelated to the patient’s underlying condition. A root cause analysis is considered for other cases that also appear to represent significant systems breakdown.
The risk manager and quality adviser create a high-level flow diagram of the event as it unfolded. This flow diagram and a brief narrative description of the event are used at a meeting to discuss the event. The medical director invites every individual involved in the care of the patient in question. The attendees always include physicians and nurses and often include pharmacists, physical therapists or others.
These meetings are cofacilitated by one of the physician members of the SEARCHES Committee and the quality adviser. This tandem leadership has been very effective in providing two unique perspectives. The meetings are opened with a statement outlining the confidential, nonjudgmental nature of the process. The leaders are very skilled at maintaining a blame-free environment.
The meeting’s first step is to explicate the facts about what occurred. Participants describe their actions during their involvement with the patient. Secondly, participants identify any factors they may have observed that contributed to the unanticipated event. Lastly, the group generates potential strategies that would address the contributing factors identified.
Significant follow-up work is generated from each RCA meeting. A subgroup of participants works with the co-leaders of the process to further develop, implement and evaluate risk reduction strategies. The strategies are designed to eliminate the risk, mitigate the risk or reduce the risk. The SEARCHES Committee reviews each risk reduction plan and determines the appropriateness of planned strategies. Summary reports are submitted to the Quality Council and senior management on a periodic basis.
Uncovering Systemic Problems
The greatest success of DHMC’s review process has been in switching the focus from whom to blame to seeking to uncover systemic barriers to the best possible care. Participants in the RCA meetings routinely report feeling supported in their sharing of sometimes troubling information. They also say that they often make changes in individual practice to decrease the probability of recurrence. A tribute to the success of the process is that many individuals who have been involved in one RCA have begun to refer an increasing number of cases for review.
Many RCAs have spawned improvement efforts. Positive changes include implementing standard order sets for high-risk cohorts of patients; clearly delineating urgency codes for communicating patient status and assuring timely response to emergent needs of other patients; altering medication labeling and storage to decrease confusion; and making changes in the cardiac arrest response team to more clearly identify the person in charge.
Polly Campion, MS, RN, is director, Clinical Quality Resources, Dartmouth-Hitchcock Medical Center.