With adverse events, don’t stick your head in the sand

Adverse event reports can strengthen QI

The phrase "adverse event outcome reports" might make you want to run and hide, but these reports can be a wealth of information and require constant attention by all home health agencies, according to experts interviewed by Hospital Home Health.

"Adverse event reports help us monitor the quality of our care and assess the validity of our OASIS [Outcomes and Assessment Information Set] assessments," says Jeannie Snyder, RN, BSN, CQI coordinator for Sacred Heart Home Health Services in Eugene, OR. "By reviewing them on a regular basis, we also have a chance to address issues raised by the reports before a surveyor brings them to our attention," she adds.

The most common reason for an adverse event report for her agency has been falls, Snyder adds. "We have a large number of weak, elderly, debilitated patients and no matter how much information the nurse provides to avoid falls, the patients do get up in the middle of the night and fall," she continues.

After monitoring the adverse event information related to falls, Snyder’s nurses changed the focus of their teaching from preventing falls to learning how to fall safely, she says. "We teach patients to grab onto a bar or table to slow their fall so their landing won’t be so hard," she explains. "We also recommend hip protectors or pads under and around the bed to soften the fall and prevent fractures."

Efforts from this change have been positive, Snyder points out. "In 2000, we had 63 patients access the emergency department [ED] following a fall, and 42 of the patients had fractures," she says. These numbers steadily have dropped. In 2001, 49 patients went to the ED, and 19 had fractures. In 2002, 56 patients went to the ED, but only 15 had fractures. In the first six months of 2003, 19 went to the ED, and six had fractures.

To use adverse event reports most effectively, you must have a process in place to regularly review the reports, audit the charts involved, and determine the reason the adverse event occurred, Snyder says. "We download our reports monthly, then our continuous quality improvement (CQI) staff review the report and have medical records pull the appropriate charts," she explains. "The charts are placed in a staff auditing area next to CQI, and letters are sent to the appropriate case managers along with the audit forms for the specific adverse event," she says.

The staff are so tuned into the process that sometimes staff members will ask for an audit form as soon as they’ve completed a transfer or a discharge OASIS and know that it will generate an adverse event, says Snyder. "They say it is easier to complete the form and document the care while it is fresh in their mind rather than one month later," she adds.

Having the case managers and the nurses involved in the audits is an important teaching component of the process, says Snyder. "No matter how much you teach OASIS, there are still many items that require subjective judgment, and the audits demonstrate how an inaccurate assessment can result in an adverse event," she says. By seeing real-life examples of different situations, nurses more easily can identify the same situation in another patient, she adds.

Use a team approach

At Home Health Care of Washington County Hospital in Hagerstown, MD, staff members review the adverse event information quarterly and evaluate the information in multidisciplinary teams, says Barbara Leatherman, RN, performance improvement coordinator for the agency. The teams are responsible for presenting the information to staff meetings and developing recommendations for improvement. Different staff members serve on the task forces each quarter so everyone has an opportunity to learn more about OASIS, adverse events, and performance improvement, she says. "A recent surveyor was very impressed with our task force approach," she adds.

Whether you use individual nurses or a task force to audit the charts, the audit will produce one of four results, Snyder explains.

1. Data entry error

The staff checked the correct box, but the data entry staff coded it wrong on submission. "We still have a problem with this occasionally because we do all of our OASIS on paper," she says.

2. OASIS error

Staff had incorrect information or checked the wrong box. "This sometimes happens when different clinicians handle the start of care and the discharge OASIS," explains Snyder.

When your audits do show OASIS errors as the reason for the adverse event, use the information to improve your educational focus, suggests Leatherman. "Over the past year, we have looked at all OASIS questions and given staff members additional information and definitions for them to use to improve their accuracy," she says.

3. Unpreventable adverse event

"Some events, such as falls, occur even when all appropriate care and teaching was provided and documented," says Snyder. If you see trends in certain unpreventable adverse events, use the information as a way to evaluate your teaching, but be aware that some adverse events are going to occur in spite of your best efforts, she adds.

4. Quality concern

Sometime a chart audit will show a true quality concern such as wounds that are not properly measured, assessed, or documented at each visit, says Snyder. These finding should prompt action within the agency to further educate the staff, she adds.

Surveyors are using adverse event reports to focus their surveys, says Leatherman. "Our surveyor showed up with her report in her hand and asked me what I thought of our most recent report," she says. "Because we work with the information on a regular basis, I was able to show that I understood the information and that our agency used the information in a constructive way," she adds. "I like using the reports because it enables us to benchmark against other agencies and track results over time," says Leatherman. "More importantly, they enable us to identify quality of care concerns that are relevant to our agency and our patient population."

For more information on learning from adverse events, contact:

• Barbara Leatherman, RN, Performance Improvement Coordinator, Home Health Care of Washington County Hospital, 1799 Howell Road, Hagerstown, MD 21740. Telephone: (301) 766-7815. E-mail: bleather@wchsys.org.

• Jeannie Snyder, RN, BSN, CQI Coordinator, Sacred Heart Home Health Services, 1121 Fairfield Drive, Eugene, OR 97402. Telephone: (541) 607-8157. E-mail: jesnyder@peacehealth.org.