Performance Improvement Tip of the Day: Improving Performance after a Serious Clinical Adverse Event

A recently published whitepaper by IHI outlines an excellent proactive approach to responding to serious clinical adverse events: http://fb.me/1h1CfU9vm

A robust improvement plan is critical to the response to a serious clinical adverse event. This is often what the patient, family, and/or staff are looking for in order to rebuild confidence in the care, systems, and institution. The issue brings to mind an example of a serious clinical adverse event that I was involved in assessing:

An elderly female patient was seen in the emergency room after falling and hitting her chest. She was admitted for chest pain, "rule out MI". However, multiple rib fractures were missed on the X-rays. She continued to have pain post discharge, and was subsequently readmitted, at which point the rib fracture diagnosis was made. Her second hospitalization was prolonged - complicated by overmedication with narcotics for pain, renal failure, aspiration pneumonia, traumatic lung injury - leading to her ultimate demise in hospital. Family members were distraught about the original "missed diagnosis" as well as several other care coordination issues ("was she being monitored appropriately?", "how could she develop all of these complications in the hospital?").

The hospital conducted a series of root cause analyses on the case - including all of the practioners involved in the care of the patient: Hospitalist, ED MD, ICU MD, General Surgeon, Anesthesia, Nursing. The root cause was determined to be "lack of awareness and systems to diagnose multiple trauma in elderly patients post fall". This was addressed through communication at staff meetings. The Chiefs of respective departments immediately pulled together a "rib fracture protocol" to help clinicians better diagnose and manage patients with low-impact trauma. Other issues identified by the root cause analyses were also tended to: improving pain management in elderly patients by increasing awareness of hospitalists and coordination with pain service; and ensuring adequate monitoring of acutely ill patients by reinforcing monitoring guidelines.

Ultimately it was the conclusion of the hospital staff that this patient's outcome would likely not have changed due to the underlying traumatic injury. However, the patient's family and all staff would have felt more confident if the right systems were in place to ensure that the right care was delivered at each interaction. The improvement plan above went a long way towards ensuring that future patients would receive the required care. The plan was communicated to the patient's family, along with other findings of the root cause analyses, and responses to their other questions. The depth of inquiry, level of transparency, open communication, and approach to improvement all helped to mitigate the family's concerns.