RL SOLUTIONS Safety Event Reporting Learning Objectives How to report a safety event - A safety event case scenario Getting into RL solutions Tips for writing a good safety event report

A safety event case scenario Why did my patient seize for one hour A safety event case scenario Why did my patient seize for one hour? Case: You are a busy resident on an inpatient floor. You come to realize that one of your floor patients must have been in status epilepticus for 1 hour without receiving proper treatment.  You decide to file an RL solution – 2 ways 1. YNHH Intranet 2. EPIC

Avoid: A nurse failed to communicate the patient’s change in clinical status in an effective manner. I feel bad that the patient ended up seizing for 1 hour before getting Ativan. The patient’s wife was so upset. The staff on the floor should be trained better to recognize various forms of seizures. Recommend: There was a delay in treatment for an emergent condition during the time of hospital-wide surge and increased workload. A floor nurse texted a resident two times to evaluate a patient; the messages were lacking in detail. When the resident arrived, the patient was found to be having seizures which likely were on-going for past 1 hour. Please see the progress note on October 1st for detailed sequence of events. The following may help to prevent this adverse event in the future: optimizing workload of medical team, improving communication among the medical team members, educating staff on how to recognize seizures, and educating house-staff on how to better prioritize tasks.

Tips for writing a good safety event report A good incident report will ensure questions relevant to who, what, when, where, how and why are completed. It doesn’t have to be long - stay clear and focused! Ok to reference your progress note in the event report to keep it brief Do not play the blame game. Be objective and neutral. Department of Health 2011, Victorian health incident management policy guide p.8 http://www.health.vic.gov.au/clinrisk/vhims