GETTING ON THE RADAR: TRACKING AND MANAGING

NON-ROUTINE EVENTS

Shannon Kilkelly, D.O.Assistant Professor

Department of AnesthesiologyVanderbilt University Medical Center

Why This Matters

Practitioner Problems vs System Problems Focus Targets of Educational and Training

Programs $$$ Tort Protection Governmental Regulatory Requirements Improved Quality of Care for Our Patients

What is a Non-Routine Event?

Myoclonus during an Etomidate induction? 4 beat run of monomorphic VT? Bradycardia during a retrobulbar block? Dental Injury during Intubation? Pneumothorax during Central Line Placement? A non-judgemental , non-blame assigning way

of describing events that potentially could have been, or actually were, harmful to our patients Formerly called morbidities, mortalities, Adverse

events, or Errors Let Conscience and Common Sense Guide You

Tracking NREs

Self Reporting via E-ACR systems

NACOR / AIRS Intranet Online

Reporting Systems E-mail Phone Calls Curbsides Post –op interviews EHR Database

Queries

Intraoperative Self reporting of events

Intranet Online Reporting Tool

Direct Interpersonal Reporting

Postop Satisfaction(Complaint Tracking)

E-Mail Reporting*

MCE3: Patient stated that she was having difficulty understanding the anesthesiologist due to his accent. And because of the communication problem, she felt he was not listening to her concerns regarding her allergies. She stated that he kept questioning her regarding whether it was a true allergy or just a side effect.

MCE3: Patient stated that she had a difficult time awakening and felt very groggy and felt that she was not able to get a breath. She stated that this was the worst time she has had in the last 5 surgeries.

Electronic Health Record Database Queries

QI Database of all reported events (Excel)

Review of Self reported events (links to documentation)

Sorting it Out

CARE RELATED PROFESSIONALISM RELATED

Triaging Care-Related Events

Class 1 Aspiration, cardiac arrest, Death < 48hrs post-

op Class 2

re-intubation (uneventful), Peri-op MI (non-fatal)

Class 3 HD stable Dysrhythmias, Bronchospasm

Class 4 Dental injury, blood wastage, urinary retention

Sources of Information

The Medical Record H&P Operative Reports Pre-op RN paperwork Circulating RN Documentation Code Recording Sheets Anesthetic Care Records

Billing Records / Pharmacy Charge Sheets Banked data from OR / PACU / ICU

monitors Personal Interview*

The Personal Interview

Start with the Material Witnesses Face – to – face is best If possible, make notes afterwards Ask open-ended questions Acknowledge expertise Leave open the possibility of re-interview Save the main event for last Behavior and responses during the

interview can be key in determining outcome

The Personal Interview

MORE LIKE THIS LESS LIKE THIS

Reaching a Conclusion

The Bad Outcome was Anticipated Care Appropriate Care Potentially

contributed to the outcome

Care definitely contributed to the outcome

The Bad Outcome was Unanticipated Care Appropriate Care potentially

contributed to the outcome

Care definitely contributed to the outcome

The Next Steps

Practitioner Problem History Circumstance Informal

counseling Peer Review

Committee Remediation Reassignment Limitation of clinical

duty

Systems-Based Problem Frequency of the

event Multiple

practitioners Multiple sites QMM&I committee

Re-engineering of process

Workflow Resource re-allocation

Quality and Patient Safety Director

Morbidity, Mortality

Improvement Committee

Peer Review Committee

VeritasVPIMS/Admin Data

Phone Reports to Quality

Office

Direct Verbal/ Email Reports

VC Clinical, Dept. Chair

Division Chief

Close Case

Joint QMMI Conference

Departmental MMI

Conference

Project Development-Assignment to

individual/group

Automated:• Biochemical

Markers• Chart Scanning

Just One More Thing…