Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)
{"title":"Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events","authors":"Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)","doi":"10.1016/j.jcjq.2024.03.012","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><p>Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.</p></div><div><h3>Methods</h3><p>Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.</p></div><div><h3>Results</h3><p>In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (<em>p</em> < 0.0001).</p></div><div><h3>Conclusion</h3><p>Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 492-499"},"PeriodicalIF":2.3000,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Joint Commission journal on quality and patient safety","FirstCategoryId":"1085","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S1553725024000886","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
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Abstract
Background
Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.
Methods
Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.
Results
In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (p < 0.0001).
Conclusion
Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.
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