These tools show cause of close calls, adverse events

These are the categories of triage questions used by the Veterans Affairs’ National Center for Patient Safety (NCPS) to help health care providers determine what really led to an adverse event or close call. The NCPS training tools provide specific questions you can ask in each category. For more information on this tool and others used by the NCPS, see the NCPS web site at www.patientsafety.gov.

Human Factors/Communication: Questions that help assess issues related to communication, flow of information, and availability of information as needed. These questions also reveal the importance of communication in use of equipment and application of policy and procedure, unintended barriers to communication, and the organization’s culture with regard to sharing information.

For example: A patient without an identification bracelet is administered medication based on the nurse’s memory of the patient’s identity. The hospital has a policy requiring that wrist bracelets be checked before every dose of medicine, but because the dose is overdue, the nurse delivers the medicine without confirming the patient’s identity.

Human Factors/Training: Questions that help assess issues related to routine job training, special training, and continuing education; including the timing of that training. Training issues may concern application of approved procedures, correct use of equipment, or appropriate manipulation of protective barriers. These questions also focus attention on the interfaces between people, workspace, and equipment.

For example: A new group of physicians in residency training arrived this week to start a rotation at your facility. A lab error occurs when the wrong form is submitted with a blood vial.

Human Factors Fatigue/Scheduling: Questions that weigh the influence of stress and fatigue that may result from change, scheduling and staffing issues, sleep deprivation, or environmental distractions such as noise. These questions also evaluate relationships to training issues, equipment use, management concern and involvement.

For example: Renovation is taking place in adjoining space, making it difficult for staff to converse and to hear patient call alarms.

Environment/Equipment: Questions to help evaluate factors related to use and location of equipment; fire protection and disaster drills; codes, specifications, and regulations; the general suitability of the environment; and the possibility of recovery after an error has occurred. These questions show that what appears to be equipment failure may relate to human factors issues, policy and procedure questions, and training needs.

For example: Housekeeping staff are thorough in their care of bedding material. While the patient is in physical therapy, they flip a patient’s air-filled anti-decubitis mattress inadvertently, reversing the correct alignment of the air chambers.

Rules/Policies/Procedures: Questions that help assess the existence and ready accessibility of directives including technical information for assessing risk, mechanisms for feedback on key processes, effective interventions developed after previous events, compliance with national policies, the usefulness of and incentives for compliance with codes, standards, and regulations. The qualifications of the facility and employees for the level of care provided; orientation and training for compliance with safety and security measures including handling of hazardous material and emergency preparedness; and the availability of information to all part-time, temporary, or voluntary workers and students also are considered.

For example: A nurse hired for the day through the local registry is not familiar with your facility’s policy against unlocking the door to the balcony in order to smoke while taking a break.

Barriers: Barriers protect people and property from adverse events. Questions assess barrier strength, fault tolerance, function and interaction/relationship to Rules/Policies/Procedures and Environment/Equipment.

For example: A negative pressure room for an infectious patient is a barrier to the spread of the disease. If the ventilation in the room stops working, a critical barrier has been compromised.