18 What emergency and failure-mode responses have been planned and tested? Describe variances in expected process due to an actual emergency or failure mode response in connection to the Related to this event, what safety evaluations and drills have been conducted and at what frequency (e.g. mock code blue, rapid response, behavioral emergencies, patient abduction or patient elopement)? Emergency responses may include, but are not limited to: Fire External disaster Mass casualty Medical emergency Failure mode responses may include, but are not limited to: Computer down time Diversion planning Facility construction Power loss Utility issues 19 How does the organization’s culture support risk reduction? How does the overall culture encourage change, suggestions, and warnings from staff regarding situations or problematic areas? How does leadership demonstrate the organization’s culture and safety values? How does the organization measure culture and safety? How does leadership address disruptive behavior? How does leadership establish methods to identify areas of risk or access employee suggestions for change? How are changes implemented?
24 How might technology be introduced or redesigned to reduce risks in the future? Describe any future plans for implementation or redesign. Describe the ideal technology system that can help mitigate potential adverse events in the future. CORRECTIVE ACTIONS Root Cause Types (Table A-1) Causal Factors/Root Cause Details (Table A-1) Corrective Actions Action Strength (Table A-2) Measure of Success (Numerator / Denominator) (Table A-3) Sample Size (Table A-4) Action Item #1: Action Item #2:
workforce factors Appropriate rules/policies/procedure or lack thereof Failure to provide appropriate staffing or correct a problem Failure to provide necessary information Organizational culture/leadership Organizational-level failure to correct a known problem and/or provide resource support including staffing Workplace climate/institutional culture Leadership commitment to patient safety Table A-2. Action Strength Action Strength Action Category Example Stronger Actions (These tasks require less reliance on humans to remember to perform the task correctly) Architectural/physical plant changes Replace revolving doors at the main patient entrance into the building with powered sliding or swinging doors to reduce patient falls. New devices with usability testing Perform heuristic tests of outpatient blood glucose meters and test strips and select the most appropriate for the patient population being served. Engineering control (forcing function) Eliminate the use of universal adaptors and peripheral devices for medical equipment and use tubing/fittings that can only be connected the correct way (e.g., IV tubing and connectors that cannot physically be connected to sequential compression devices [SCDs]). Simplify process Remove unnecessary steps in a process. Standardize on equipment or process Standardize the make and of medication pumps used throughout the institution. Use bar coding for medication administration. Tangible involvement by leadership Participate in unit patient safety evaluations and interact with staff; support the RCA2 process (root cause analysis and action); purchase needed equipment; ensure staffing and workload are balanced. Intermediate Actions Redundancy Use two registered nurses to independently calculate high-risk medication dosages. Increase in staffing/decrease in workload Make float staff available to assist when workloads peak during the day. Software enhancements, modifications Use computer alerts for drug–drug interactions.