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recovery – planned and unplanned (See barrier)
A recovery refers to the prevention of a misadventure or a no harm event due to some action taken the identifies and corrects the error.
Recovery actions, which are present in all near miss events, can be planned or unplanned. The recovery is planned if it results from a barrier, such as a check point in the work process, that was designed to catch mistakes or ensure quliaty. However, the recovery is unplanned if it results from an accidental or lucky catch.
recovery side (See causal tree)
Below the consequent event, the causal tree is divided into two sides— the failure side and the recovery side.
The recovery side of the causal tree is only used in the case of a near miss event. If the event was a near miss, the recovery side of the causal tree provides information on how the event was stopped from developing into a misadventure or no harm event. If the event actually occurred (misadventure or no harm event), the recovery side is left blank.
Recoveries can be planned (e.g., check point in work process) or unplanned (e.g., accidental discovery of an error).
risk
A major goal of the MERS-TM process is to reduce risk – both to the patient/donor and to the organization.
Risk equals the potential severity of the event multiplied by the probability of recurrence (will the event happen again?).
RISK = Severity X Recurrence
The Risk Assessment Index form (RAI) provides a method for assessing risk for a single event and assigning a risk index that indicates whether or not that event requires additional investigation.
RAI (Risk Assessment Index)
On the Risk Assessment Index:
- Severity is the Quantified Estimate of Severity of patient harm or QES.
- Probability is the Quantified Estimate of Probability of recurrence or QEP
Using the Risk Assessment Index (RAI), you will estimate the severity and recurrence probability using a six-level scale from Very Low to Extremely High. Each of the six levels has been assigned a numerical value.
On the RAI, the estimated QES and QEP levels have been multiplied (Severity X Probability of Recurrence) and the resulting risk values provided.
To get from the initial value to the final risk index, an adjustment must be considered based on the following two factors:
- If the product was issued – add .2 to the risk value
- If an unplanned recovery occurred – add .1 to the risk value
As a general rule, the higher the risk index, the more serious the event.
Using the RAI, MERS-TM recommends that a root cause analysis be conducted if the risk index obtained is greater than or equal to .5.
For each reported event, the estimated values for the QES and QEP, and the final risk index will be entered onto the Event Discovery Report form.
reckless conduct standard
The reckless conduct standard provides a way to determine whether or not disciplinary action is warranted by focusing on the intent toward the risk to the donor/patient.
Beyond the intentional violation of safe practice standard, the reckless conduct standard looks past the intentional violation of the rule to the intent toward the risk to the donor/patient.
For example, consider the scenario with the nurse who intentionally did not check the patient’s wristband before administering medication. Under the reckless conduct standard the nurse would not be automatically disciplined for the intentional rule violation.
Instead, the question would be whether or not the nurse understood the risk to the patient of not checking the wristband when the action was taken.
Whether or not the nurse acted with reckless conduct can be determined by examining the event closely and asking the following questions:
- Was the risk taken by the nurse "substantial"?
- Was it "unjustified"?
- Did the nurse understand the risk and act in "conscious disregard of the risk"?
If the answer to these questions is "yes," then the nurse was reckless toward injury or potential injury to the patient and disciplinary action is warranted.
The reckless conduct standard is also the stronger of the two standards in that it:
- anticipates that unhealthy habits or behaviors will exist and grow within an organization (rule violations will occur)
- allows safe reporting of "at-risk" behaviors as long as the risk was not understood or was incorrectly perceived by the employee
- allows safe reporting of events arising from violation of safe practice if violation was justified
root cause (See root cause analysis)
The root causes are factors that contribute to the generation of an event. They take place prior to or early in the event timeline. Root causes can be classified into the following types:
- latent conditions—technical or organizational
- active or human error categories—skill-based, rule-based, or knowledge-based
- other—factors related to the patient or blood donor, or factors that are unclassifiable
Once the root causes are identified and coded, they can be used to provide a more realistic view of how a system is actually working, as well as contribute to the creation of effective and lasting solutions.
root cause analysis
MERS-TM uses a technique known as root cause analysis to uncover what the underlying factors, circumstances, and decisions were that contributed to the event in question. The outcome of the analysis is represented as a causal tree. A tree provides a visual representation or diagram of the event that includes all possible causes (and recoveries) gathered during the investigation of the event.
The investigator gathers information from individuals involved in the event by repeatedly asking why. This process elicits data at multiple levels and defines the actions and decisions leading up to the event.
The final product of the root cause analysis are root causes that are described, coded, and ultimately entered into the database.
root cause codes
Root cause codes are codes assigned to the root causes of an event. The Eindhoven Classification Model (developed by Van der Schaaf) was selected as the causal classification scheme for MERS-TM.
Three major categories of root causes are:
- technical (equipment, software, forms)
- organizational (policies, procedures and protocols)
- human causes (knowledge-based, rule-based, and skill based)
The Eindhoven classification is consistent with Reason’s latent and active error theory and with Rasmussen’s classification for human behavior (skill-, rule-, and knowledge-based).
rough root cause codes
Rough causal codes are assigned during a routine investigation and entered on the QA SysOp Investigation Report. The codes used are the same as those used in building a causal tree; however, they are "rough" because the codes have been assigned through a less rigorous process for determining cause.
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