Introduction

Health care organizations are learning that their ability to maintain quality of care is directly tied to the way they approach and address patient safety issues. The goal of this post is to teach you how to identify quality events, understand their root causes, and apply a systematic approach to preventing them from recurring.

Quality events and the triggers

Identifying quality events and the triggers that lead to them are critical to the success of any improvement effort. Quality events are patient harm, a near miss, or a failure to follow a process. These events can be identified by the people who experience them, or by the people who observe them.

You will want to look for quality events in your organization that can help identify where improvement efforts should be focused.

A quality event is an opportunity for change because they lead to an opportunity for improvement.

Root cause or causes of quality events

The first step to addressing a quality event is to develop an understanding of its root cause or causes. This includes:

• Understanding the impact on patients and families
• Understanding the impact on staff
• Understanding the impact on your organization’s reputation among patients, other healthcare providers, and other stakeholders in the community

You can also do a 3×5 why analysis to find the root cause.

Not all incidents are quality events

To address a quality event, you must first understand what it is. The term quality event has two main definitions:

• An incident that has occurred as a result of poor quality; and
• A set of conditions that cause an incident to occur (quality-related).

The definition of a quality event trigger is the set of conditions that causes a quality event to occur (quality-related).

In addition, there are several types of triggers:

• Quality Event Trigger – An event in which an individual makes a decision based on inadequate information or data. Example: A doctor gives you incorrect instructions because he did not have access to all your records before treating you for your cold sore. This can lead to worse outcomes than if he had read all your medical history before diagnosing and treating.

Address every quality event as if it could result in patient harm if it recurs.

• It’s important to address every quality event as if it could result in patient harm if it recurs.
• Make sure you are aware of the potential for recurrence, which means you need to know how often similar events occur in your practice and what factors increase their likelihood.
• Make sure you’re aware of the potential for harm to patients because that will help you assess whether an event should be considered serious enough for further investigation or intervention.
• If there is any possibility of harm to staff members, this should be a red flag for immediate intervention because it would affect other employees’ ability to do their jobs well and safely.

Isolocity has an entire module to address this concern. In our corrective and preventative action module, all erroneous actions are recorded. To prevent them from reoccurring in the future, a plan is also to be submitted.  Most of the tasks are also automated, for e.g. through real-time statistical process control, a graph is updated on your quality KPI dashboard as each part is inspected. This graph will indicate if machine maintenance is needed even before any waste is created.

Conclusion

Taking a proactive approach to quality events can help you prevent them from happening in the future and provide immediate action to reduce patient harm if they do occur. It is important to note that not all quality events are considered high risk, but as we have seen here today, sometimes even small problems can cause serious harm. Therefore it is critical to address every event as if it could result in patient harm if it recurs.

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