Français

Quality improvement


Learning from adverse events (accidents in Québec)

Formal reviews (Page 1 of 2)


Group of physicians around a deskTwo types of reviews of harm from healthcare delivery are typically used by leaders and managers in Canadian hospitals: quality improvement reviews and accountability reviews.

Quality improvement reviews

Quality improvement (QI) reviews are designed to identify the reasons for adverse events or near misses by examining the system and processes by which healthcare is provided.  

To be meaningful, QI reviews should include candid and detailed assessments by the providers involved. In addition to reviewing known facts, it is often helpful to consider what could have happened or what the participants wished had happened.

Discussions may include hypothesizing and speculating about weaknesses in system processes. This can be a useful way to identify possible reasons for the clinical outcomes and to develop strategies to try to prevent reoccurrences.

To encourage the full participation of providers, legislation exists in each province/territory that generally protects the work of a quality improvement committee. This legislation reflects the public policy objective of encouraging healthcare providers to participate in quality improvement.  

The QI review may confirm the clinical outcome resulted from the patient's underlying medical condition or the risks inherent in an investigation or treatment. Conversely, the review may identify system vulnerabilities or failures.  

Following the analysis, the patient should be informed of new facts identified in the analysis of the event and the conclusions about the reasons for the clinical outcome. The deliberations, or opinions and speculations discussed in the review should not be disclosed. An apology may be warranted.

Patients will often want to know what steps, if any, have been implemented to prevent similar harm to others, and it is appropriate to share this information.

Case: A 16-year-old male with leukemia
Young male patient wearing a bandana

Background

A 16-year-old male is diagnosed with leukemia.

During the last cycle of chemotherapy, his oncologist is running behind schedule and asks a junior resident to administer three chemotherapeutic agents to the patient. The pharmacy sends all three drugs in the same medication pouch. The resident has had little orientation to the oncology service and attempts to seek clarity from the supervising oncologist without success.

Background continued

All three drugs, already in preloaded syringes, are administered intrathecally. However, one of the drugs, vincristine, should be given intravenously.

The healthcare providers involved promptly provide the parents with information about the clinical condition of their son, giving them an initial understanding of the facts about what has happened, as well as emotional support.

Outcome

Despite all rescue efforts, the young patient dies 3 days later. The coroner (medical examiner) is immediately notified.

Think about it

Could a similar medication adverse event occur in your hospital? What would be the response of your leaders?
Previous
Next

Group of healthcare professionals around a desk

Alternative approach

The preceding case describes a real occurrence in Canada. The following is a fictional description of how this serious adverse event could be handled in a just culture of safety. The approach reflects what many patient safety experts and the CMPA see as a fair and effective way to improve the quality of patient care and prevent other similar occurrences.
  1. The leaders of the hospital do not rush to prejudge and blame the providers for what has happened. Rather, they try to understand the circumstances and context for the decisions and actions during the event.

    A preliminary collection of facts shows there was no deliberate violation of policy or deliberate misconduct. The resident's lack of knowledge or skills is considered largely a shortcoming in the orientation to the oncology service.

    The hospital determines the system of care needs improvement.

  2. The hospital reassures the distraught parents that a QI review will be held and what they could expect to learn from it.

  3. The QI review is conducted by a properly constituted quality improvement committee.

    To gain a broader perspective, the hospital reviews a number of medication policies and practices.

    Knowing that the focus is on learning and that their remarks would not be used against them in other forums, several physicians, nurses, and pharmacists, including those involved in the event itself, take part. The group avoids finger pointing and blaming.

    Using the patient safety incident analysis approach, the healthcare providers speculate and hypothesize on what could have been done differently in the system, both in this case and in the future.

  4. The committee comes to an understanding of the facts about what happened and identifies several contributing system failures:
    • inadequate team communication
    • little orientation and supervision of new staff
    • confusing packaging and labelling of medications and syringes
    • no double checks for certain medications and routes by separate providers
    • less-than-ideal physical areas for preparing and administering high-risk medications
    • inadequate monitoring
    • lack of a policy for administering medications
  5. The hospital makes a number of changes.

    The orientation for all new medical, nursing, and support staff is improved.

    The hospital also improves the procedure for delivering medications to the ward. It develops, tests, and implements policies for handling high-alert medications.

    Syringes containing vincristine are now flagged with a warning against intrathecal use.

    Many other medication safety practices are introduced including better labelling, segregation of drugs that look similar (look-alike medications) and have similar-sounding names (sound-alike medications), read backs, and clearer writing of drug orders.

  6. The hospital leaders and the providers involved give the parents a factual understanding of what has occurred, as well as an apology. They discuss the steps that are being taken to improve the medication practices at the hospital.

    A similar tragedy has not occurred since, and serious medication adverse events have decreased overall.