1. Critical Event Review (Root Cause Analysis)
Hutchinson Area
Health Care
December 2008

2. What are we going to cover?
What is Critical Event Review (CER)?
Brief Overview
Reasons for conducting a Critical Event Review
Hutchinson Area Health Care’s use in
Long Term Care - Process
Story

3. What is a Critical Event Review?
A process that uses a systems approach for identifying the basic causes for an undesirable event or problem
Focus on the process and systems, not individuals
Uses the technique of asking the “why” question multiple times
A confidential process

4. Reasons to do a Critical Event Review
It is a review process used to uncover the facts and the underlying story that led up to the event
Identification of contributing factors
More in-depth understanding of the sequence of events
Assists in improving facility systems/processes
Promotes proactive Action Plan development to assist in preventing recurrence
Resident Safety
Reduce the harm to residents by increasing the resilience of our responses when the event repeats

5. Events where use of CER could be considered…
Events with serious outcome for the resident
Repeating incidents
Near Misses/Good Catches
Examples:
Falls
Medication Errors
Plan of Care not followed

6. CER Selection Criteria
Initially Joint Commission driven
Sentinel event standard requiring RCA’s to be done
Was applied to CMS sentinel event criteria
Based on event data analysis
Highest event (falls)
Severity
Resident safety focus – reduction of harm
Future – working to be proactive – near miss

7. Immediate Actions Ensure resident and staff are safe
Notification of Administration
Assess need for additional resources
Secure equipment, tubing, medications, involved in event
Communication to resident and family

8. Immediate Actions (continued)
Complete documentation by the care provider
Medical Record: Facts- Objective data/description of event
Event/Incident Report
Institute an immediate corrective action if possible
Staff Notes (not part of the medical record)
Coach staff: record when resident last seen, what they heard, room arrangement, location of equipment, your response
Who, What, When, Where, Why
Staff notes need to turned into
Quality Department or Quality Manager
Drawings/Pictures

9. CER Meeting Steps
Set up initial meeting 48 to 72 hours post event (if not sooner)
Who sets up the meeting
Identify and invite key players
Won’t compromise resident safety
Admin. Assistant schedules – tell briefly why important to come (to reduce fear of unknown)

10. Key Players
Staff from departments/units directly and indirectly involved in the event
Nursing Administration
Medical Director
Physician/Provider as needed
Quality Representative
Administrator
Facilitator
Others as identified
Talk about example – hospice, community involvement, etc.

11. CER Meeting Steps (continued)
Coaching Staff
May be initiated prior to meeting being set up if member has not participated before
Participation in the CER is an opportunity to learn
Chance for staff to tell their story
Emphasis is on improving the system
Just in Time Training
TALK ABOUT BARRIERS – OVERTIME, DON’T WANT TO COME IN

12. Meeting Preparation Room with comfortable atmosphere
Flip Chart and Markers
Kleenex
Coffee/Water/Treats
Medical Record/Reports
Any of the pre-work documentation
Staff Notes
Chart Review
Lead nursing completes
Time line of the event

13. Facilitator Team training/group skills
Clinical background can be helpful, but not required
Listening skills – use facilitation to uncover the story behind the event
Analytical skills – conversational/timeline versus investigation data gathering
Positive – sense of humor – sensitive – deal with emotions – awareness
Strong boundaries
Brings people back to focus
Ability to manage emotion at the table – fear/anger
Is able to identify and draw out people
Engages the entire team to give their perspective
Need to support everyone’s style

14. Recorder
Recorder – listen to how they are saying, as well as what they are saying
Facilitator may be the recorder as well
Would recommend a recorder be available

15. Meeting Format Introductions and Ground Rules Brief orientation to CER
Confidentiality
Titles left at the door - all members need to be active participants
There are no bad questions
Systems and process focus
Not blaming/finger pointing
Want to foster creativity
“You” have the solutions
Brief orientation to CER

16. CER Meeting in Progress
Tell the story
Brief overview of resident
Start with the person who found resident
Try to obtain details of what happened
What did you see?
Encourage people to share
Facilitator stands in front and captures data on white flip chart
“BIN” list – gives credence, but allows facilitator to move back to subject
Try to identify opportunities /gaps as the story is presented
Why, Why, Why?
How were they laying? Where was the wheel chair?
What is the purpose having the wheel chair across the room?

17. Use of Triage Questions
Helps team understand event
Assures thoroughness of investigation – “buckets”
Human factors
Staffing
Communication/Information
Equipment/Environment
Uncontrollable external factors
Training
Rules/Policies/Procedures
Barriers

18. Forms

19. CER Meeting cont.
Identification of factors that may have influenced the circumstances that led to the event
Identification of system/process gaps
Opportunities identified for improvement
Feedback from participants on how systems can be improved is critical
Is there anything that we could have been done differently?
Development of an action plan – based on findings – with target dates and responsible party listed
Monitoring/measurement plan as indicated
(Critical Event Review Corrective Action Plan -to be covered more in depth in later presentation)
Follow-up

20. Spread the Success/knowledge
Share with staff and Administration
Need to go beyond interdisciplinary care team
Potential:
Share learnings and collaborate with other facilities
NPSG’s
Mattress

21. Critical Event Review Summary
To be thorough, a RCA must include:
Determination of human and other factors
Determine related processes and systems
Analysis of underlying causes and effects – series of why’s
Identification of risks and their potential contributions

22. Questions?
Thank you!