Healthcare Safety Event Management
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Questions and Answers

What is the first step a healthcare worker must take after identifying a safety event?

  • Consult the Legal Department
  • Document the event in the patient file
  • Notify the patient and their family
  • Notify their line manager immediately (correct)

    • All safety events must be reported anonymously.

    False

    Who must be notified about a safety event to prescribe specific treatments or investigations?

    The patient's treating doctor

    The __________ must assist in providing feedback to the patient or their family about the safety event.

    <p>PxM</p> Signup and view all the answers

    Match the steps in the management and reporting of safety events with their descriptions:

    <p>Step 1 = Initial management and verbal reporting Step 2 = Documentation and reporting of the event Step 1.1 = Notify line manager immediately Step 2.1 = Document observed events in patient file</p> Signup and view all the answers

    Which of the following pieces of information is NOT required in the Safety Event Report?

    <p>Patient’s name</p> Signup and view all the answers

    Legal advice must be obtained before engaging with the patient or their family about a safety event.

    <p>True</p> Signup and view all the answers

    What classification can the Reporter provide for the event?

    <p>The most suitable type of event as per their opinion</p> Signup and view all the answers

    What is the purpose of the After Action Review report?

    <p>To compile events investigated by the Unit/Line Manager</p> Signup and view all the answers

    The Provisional report is created only for serious reportable events (SREs) that result in minor injury.

    <p>False</p> Signup and view all the answers

    By when should all safety events be loaded and managed to closure?

    <p>By the 7th of the next month.</p> Signup and view all the answers

    The _________ report contains the London Protocol contributing factors and is preferred for serious harm and death events.

    <p>Root Cause</p> Signup and view all the answers

    Match the following report types with their descriptions:

    <p>After Action Review = Compiled by Unit/Line Manager for all events Provisional report = For SREs and serious harm events at first review Final report = Detailed systems analysis for SREs and serious harm events Root Cause report = Determination of root cause for serious harm events</p> Signup and view all the answers

    Who must be notified only once the safety event is closed?

    <p>Hospital Governance Team</p> Signup and view all the answers

    The PSM must report a safety event by the end of the work shift.

    <p>True</p> Signup and view all the answers

    Who should maintain the alert distribution email group in the hospital?

    <p>PSM or HCM/NM.</p> Signup and view all the answers

    For every safety event, alerts will be sent when they are loaded onto the Safety Event Management System by the _______ or categorized by the PSM.

    <p>Reporter</p> Signup and view all the answers

    Match the role with their corresponding responsibilities:

    <p>Unit Manager = Provides feedback to unit staff PSM = Categorizes events and provides AAR support Nursing Manager = Maintains alert distribution email group RCM = Requests additional time for complicated events</p> Signup and view all the answers

    What does ISBAR stand for in event reporting?

    <p>Information, Situation, Background, Assessment, Recommendation</p> Signup and view all the answers

    An event can be closed if no further investigation is required.

    <p>True</p> Signup and view all the answers

    What is the primary purpose of investigating serious events?

    <p>To find out what happened, why it happened, and what learning can be gained.</p> Signup and view all the answers

    The _____ is responsible for ensuring that actions determined are suitable for the event.

    <p>Unit Manager</p> Signup and view all the answers

    Match the following steps involved in event investigation:

    <p>Preliminary investigation = Gather facts and data Meeting with HCWs = Collect staff insights Collation of information = Establish event chronology Review by SEMT = Identify root cause</p> Signup and view all the answers

    Who must participate in the Serious Event Management Team (SEMT)?

    <p>Review Team members and relevant specialists</p> Signup and view all the answers

    The Regional Clinical Manager (RCM) is always part of the SEMT.

    <p>False</p> Signup and view all the answers

    What should be recorded in the CURA risk register?

    <p>The risks identified during investigations.</p> Signup and view all the answers

    The Serious Event Management Team must document the planned actions in the _____ with a due date and responsible individual.

    <p>Event Management System</p> Signup and view all the answers

    Which of the following is a key component of the investigation process?

    <p>Gathering initial facts from HCWs</p> Signup and view all the answers

    The investigation outcomes are compiled in either an ISBAR or a Root Cause Analysis report.

    <p>True</p> Signup and view all the answers

    What is the main purpose of the After Action Review (AAR)?

    <p>To identify gaps, lessons learned, and improve patient safety</p> Signup and view all the answers

    What is an example of a multi-event?

    <p>An incident that harms more than one individual or a group.</p> Signup and view all the answers

    If agency staff members are involved in an event, they must complete the electronic _____ on the Safety Event Management System.

    <p>Safety Event Report</p> Signup and view all the answers

    Only events causing serious harm or death require all questions in the AAR to be answered.

    <p>True</p> Signup and view all the answers

    Match the following components of the reporting process with their descriptions:

    <p>Initial report = Based on information before investigation Feedback to reporter = Sent if email details are provided ISBAR report = Structured standardized format for reporting Root Cause Analysis = Investigates underlying causes of an event</p> Signup and view all the answers

    What are two main types of reviews conducted by the Unit/Line Manager following an incident?

    <p>Initial Review and After Action Review</p> Signup and view all the answers

    The process of reporting an event verbally to the Review Team is part of the ________ Review.

    <p>First Team</p> Signup and view all the answers

    Match the types of harm with the required review actions:

    <p>No harm = Complete feedback Low harm = Complete feedback Moderate harm = Complete feedback Serious harm or death = Complete all AAR questions</p> Signup and view all the answers

    What is the role of the Legal Department when an event causes harm?

    <p>To ensure MCSA's legal, financial, and reputational risks are managed</p> Signup and view all the answers

    The Unit/Line Manager must document any missing details in the AAR for low harm events.

    <p>False</p> Signup and view all the answers

    What framework must be referenced to identify contributing factors during the AAR?

    <p>Yorkshire Contributing Factors Framework</p> Signup and view all the answers

    If an event does not require further investigation, it can be asked to be __________ by the Review Team.

    <p>closed</p> Signup and view all the answers

    Match the following types of harm with their implications:

    <p>No harm = Minimal impact, do not require extensive review Low harm = Review and potential learning opportunities Moderate harm = More detailed review required Serious harm or death = Complete investigation required</p> Signup and view all the answers

    According to Just Culture principles, what should be ensured during the First Team Review?

    <p>Support staff involved access psychological help</p> Signup and view all the answers

    The Unit/Line Manager should seek legal advice for any incidents regardless of harm level.

    <p>True</p> Signup and view all the answers

    What should be done if a low harm event is a repeating incident?

    <p>Conduct an investigation to find common factors.</p> Signup and view all the answers

    The Safety Event Management System is used to document the __________ after an event.

    <p>AAR information</p> Signup and view all the answers

    Study Notes

    Initial Management and Verbal Reporting

    • The healthcare worker (HCW) identifying a safety event must immediately notify their line manager.
    • A clinical care plan should be developed to monitor the patient's response to interventions.
    • The patient's treating doctor must be notified.
    • The patient and/or their family must be informed.
    • The Patient Experience Manager (PxM) must be involved in providing feedback to the patient, family, or visitors.
    • Legal advice should be sought from the Legal Department prior to engaging with the patient, family, or visitors.

    Reporting

    • The HCW directly involved in the event or their supervisor documents what happened in the patient file.
    • The HCW completes a Safety Event Report on the Safety Event Management System before the end of the shift.
    • Reports must include the location, time, what happened, who is affected, and a short narrative description.
    • Names of patients, staff, or doctors should not appear on the report to maintain confidentiality.
    • The HCW classifies the event into the most suitable type of event.
    • The HCW can receive feedback by including their email address in the report.
    • Events can be reported anonymously, but must include the patient’s information, hospital, business unit, and unit in which it occurred.

    Initial Review and After Action Review (AAR)

    • The Unit/Line Manager conducts an Initial Review of the event to ensure completeness.
    • The Unit/Line Manager arranges a feedback or debriefing session with all staff involved.
    • The AAR helps review actions taken, identify gaps and lessons learned, and reinforce risk mitigation and prevention measures.
    • Questions to answer in the AAR include what was supposed to happen, what happened, the difference between the plan and action, what can be learned, and what will be done in the future.
    • The Unit/Line Manager documents the AAR information, including contributing factors based on the Yorkshire Contributing Factors Framework.

    First Team Review

    • The Unit/Line Manager reports the safety event verbally to the “Review Team” (nursing management, PSM, IPCM, Night Manager and Hospital Clinical Manager).
    • The Review Team ensures adherence to Just Culture principles, determines the level of review, ensures that the action loop is closed, disseminates recommendations, and learning to improve the event management process.
    • The Review Team evaluates the appropriateness of the response and recovery efforts, actions taken to prevent future harm, and support provided to HCWs.
    • The Review Team identifies all associated contributing factors.
    • Legal support must be sought for all events where there is harm or potential harm to a patient/visitor.
    • A decision is made about the need for further investigation.
    • If further investigation is required, it moves into the Categorisation (Step 4) and Investigation phase (Step 6).
    • If further investigation is not needed the event can be closed noting the classification on the Safety Event Management System.

    Categorisation of Events

    • The Patient Safety Manager (PSM) reviews the event report and the Type of Event selected by the reporter.
    • The PSM determines the correct classification of the event.
    • This step needs to occur within 5 working days of the event being reported.
    • If the event is Serious Harm or resulted in death, an initial report using the ISBAR layout should be completed by the PSM.
    • Agency staff must complete an electronic Safety Event Report, and a copy should be sent to their agency.
    • If no further investigation is required, the event can be closed and the Reporter sent feedback.
    • Principles for classifying multiple events include individual investigation of each event, identification of common causal factors or associations, and implementation of effective improvements to prevent future events.

    Investigation Using Systems Analysis Approach

    • The purpose of investigating events is to determine what happened, why it happened, and what lessons can be learned.
    • Key steps in the investigation include preliminary investigation, meeting with HCWs, collation of information, and review by the Serious Event Management Team (SEMT).
    • The PSM conducts a preliminary investigation and gathers information including initial facts, patient’s file, relevant policies and procedures, previously reported events, and consultations with colleagues or experts in the field.
    • The PSM coordinates a meeting with HCWs to gather their accounts of the event.
    • The PSM and the Unit Manager analyze the data and establish the chronology of events, identify contributing factors, recommend actions to prevent recurrence, and identify potential learning gained.
    • This step is required for events involving Severe Harm, Death, or those classified as a Serious Reportable Event (SRE).

    Review by the Serious Event Management Team (SEMT)

    • The SEMT reviews investigations conducted on Serious Harm or Death events or those classified as SREs.
    • The SEMT is composed of the Review Team members, any medical practitioner or therapeutic support healthcare provider involved in the patient’s care, and any other person who can offer technical/specialist knowledge.
    • The SEMT's purposes include identifying and defining relationships between contributing factors, developing and managing recommended actions to reduce the risk of recurrence, ensuring that actions are documented and monitored, and closing the loop by sharing lessons learned.
    • The SEMT determines whether to further investigate the event or to close it.

    Risk Assessment and Reporting

    • The Risk Assessment Scale should be completed.
    • Risks should be recorded in the CURA risk register.
    • Investigation outcomes are compiled in the ISBAR or Root Cause Analysis report by the PSM.
    • The event is then closed on the Safety Event Management System by the PSM.

    Feedback on Safety Events

    • Guidance from Legal Department must be obtained to advise on all discussions or feedback with/to the patient/visitor and/or their family.
    • Feedback should be provided to the patient and their family, ideally with the support of the PxM.
    • Feedback should be provided to unit staff by the Unit Manager and PSM.
    • The Reporter will receive feedback on the outcome of the event investigation.
    • The Hospital, Regional and Corporate Office Clinical Governance team members will receive the final report for all events that have been closed after a completed investigation.

    Types of Reports on the Safety Event Management System

    • After Action Review Report - for all events as compiled by the Unit/Line Manager.
    • Provisional Report - - for all SREs and serious harm or death events that were investigated and is completed at the time of the First Team Review.
    • Final Report - For all SRE’s and serious harm events with a detailed systems analysis investigation.
    • Root Cause Report - this is an alternative format to use when a detailed systems analysis investigation has occurred for serious harm and death events.

    Timeframes for Reporting and Management of Events

    • All safety events should be loaded and managed to closure on the Safety Event Management System by the 7th of the next month.
    • Events requiring additional time can be requested by the PSM.
    • The PSM may request additional time from the Regional Clinical Manager (RCM).

    Actions and Timeframes

    • Report a safety event: Before or by end of shift - All staff
    • AAR and contributing factors: 5 working days from event reported - Unit / Line manager
    • Categorise and finalise with Review Team: 10 working days from event reported - PSM
    • Serious reportable events that require system analysis for investigation by SEMT: 15 working days from event reported - PSM

    Alert and Notifications

    • All events captured on the Safety Event Management System go through a workflow process.
    • The PSM can email Unit managers when an event requires an AAR.
    • The Hospital Governance Team receives a notification with the relevant final report when an event is closed.
    • The Reporter receives feedback by email when the event is closed.
    • Alerts are sent for SREs and those with Severe Harm or Death.
    • Alert email groups should be maintained by the PSM or the Hospital Clinical Manager/Night Manager (HCM/NM).
    • Alert distribution email name: [email protected] (Hosp ID is the same 3 letter abbreviation of the hospital name).
    • Individuals in these roles should be included in the email group: nursing manager, deputy nursing manager(s), night duty manager(s), day clinic manager, patient safety manager, infection prevention control manager, hospital clinical manager, pharmacy manager, ward/clinical pharmacists, Regional Managers - Regional Operations Executive, Regional Clinical Manager (optional).

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    Description

    This quiz covers the essential procedures following a safety event in healthcare settings. It includes protocols for reporting, communication with patients and families, and documentation requirements. Test your knowledge on the roles of healthcare workers and management in ensuring patient safety.

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