healthcare waste management conference in africa today
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Healthcare Waste Management Conference in Africa Today. Incident Reporting A Proactive Approach. Janet Magner Healthcare Consultant Magallan Risk Services. Accidents re-occur because we do not use the knowledge we already have. Learning from Losses. - PowerPoint PPT PresentationTRANSCRIPT
Healthcare Waste Management Conference in Africa Today
Incident Reporting Incident Reporting
A Proactive Approach A Proactive Approach
Janet MagnerJanet MagnerHealthcare ConsultantHealthcare ConsultantMagallan Risk ServicesMagallan Risk Services
Accidents re-occur because we do not use the knowledge we already have
“We are slow to learn from
Experiences of Others”
Trevor A. KetzChemical Engineer
Learning from Losses
“Modern man peers eagerly back into the twilight out of which he has come, in the hope that its faint beams will illuminate the obscurity into which he is going”
E.H. CarrHistorian
“ It is searchlights, not faint beams
that shine out of the past and show us
the pits into which we will fall if we do
not look where we are going”Trevor A. Kletz
Chemical Engineer
“Normalisation of Deviance”
Risk is relative
We increase our ability to accept risk
Complacency develops
Corrie J. Pitzer - MD SAFEmap AustraliaCorrie J. Pitzer - MD SAFEmap Australia
Eeufees Disasters – 19 in 5 yrs
The healthcare environment
HC workers suffer 600,000 – 1 million injuries from needles and sharps annually
At least 1000 HC workers estimated to contract serious infections annually from needlestick and sharps injuries
Approximately 3% of needlestick injuries result in HIV exposure
Approximately 30 needlestick injuries / 100 beds / year
Nursing Facts -American Nursing Association / EPINet 1999
“Moving towards depravity”
Pascal
What is an Incident?
An unplanned sequence of events which has An unplanned sequence of events which has caused (caused (or could have caused)or could have caused) loss. loss.
(death, injury, illness, environmental or property (death, injury, illness, environmental or property damage, or business interuption, legal liability)damage, or business interuption, legal liability)
Or could have caused = potential for loss = Near Miss
The accident / near miss relationship
There are more opportunities for learningThere are more opportunities for learning
from our own and other’s experiences from our own and other’s experiences
than we can realistically process!than we can realistically process!
What conclusions can be drawn?
The Near Miss is a free object lesson !
Organization CultureOrganization Culture Fault finding rather than Fact findingFault finding rather than Fact finding Not wanting to be found “Incompetent”Not wanting to be found “Incompetent” Time wasting - extra workTime wasting - extra work Lack of trustLack of trust Fear of reprisalsFear of reprisals
Why do we not know about them?
Formulation of a healthcare industry wide CEO Formulation of a healthcare industry wide CEO
level task forcelevel task force
Blue Cross Blue shield or Michigan FoundationBlue Cross Blue shield or Michigan Foundation
American Safety Health - System Pharmacists American Safety Health - System Pharmacists
(ASHP)(ASHP)
Near miss reporting in healthcare
Uniform Nation-wide system of mandatory Uniform Nation-wide system of mandatory reportingreporting
Voluntary reporting of medical errorsVoluntary reporting of medical errors
Protection grantedProtection granted
Implementation of process channelImplementation of process channel
Research analysis and communicationResearch analysis and communication
Key areas and position
ASHP News – 18/07/2003
“There is no reluctance to talk about it any more…….”
“5 to 8 years ago errors were something to sweep under the carpet and you don’t know you have a problem unless you look under the carpet”
“Anonymous-reporting policy led to the volunteer non-punitive-reporting policy now in place”
….brainstorm how we can improve”
“the drop boxes have increased the number of near miss reporting by 5 times”
Incriminating - legal liabilityIncriminating - legal liability
Loss of confidentialityLoss of confidentiality
Punitive, ThreateningPunitive, Threatening
DemotivatingDemotivating
Criminal implications of reporting
Trends
Report Form
Opportunity to Share
Prevent Recurrence
Evaluate causes
React positively
Process to Follow – R E P O R T
React positively
Attitude of Line ManagerAttitude of Line Manager
Team ApproachTeam Approach
Well Trained Well Trained
ObjectiveObjective
Evaluate Cause
Systematic Approach – Causal / Fault Tree Systematic Approach – Causal / Fault Tree
analysisanalysis
Analyze through to basic (underlying cause)Analyze through to basic (underlying cause)
Good questioning techniques - 5 Why’sGood questioning techniques - 5 Why’s
Prevent a recurrence
Comply with PolicyComply with Policy
Effectively appliedEffectively applied
Risk not shiftedRisk not shifted
Short and Long term solutions Short and Long term solutions
Opportunity to Share
Demonstrate ConcernDemonstrate Concern
Cost ImplicationsCost Implications
Develop a culture of learningDevelop a culture of learning
(Also stands for (Also stands for OOrganized Approach) rganized Approach)
Report Form
“The job is not complete until the paper work is done”
Easy to useReadily availableDistinctive colour
All the necessary legal requirements
Trend Analysis
Trevor A. KetzChemical Engineer
Learn from Experiences of OthersLearn from Experiences of Others
Learn from our Own ExperiencesLearn from our Own Experiences
Develop a culture of Non Blame / Fact Develop a culture of Non Blame / Fact Finding / TrustFinding / Trust
Set up a reporting system that will identify Set up a reporting system that will identify and analyze critical behaviorsand analyze critical behaviors
REMEMBER - R E P O R TREMEMBER - R E P O R T
Summary
3% of needlestick injuries result in HIV exposure!
Healthcare Waste Management Conference in Africa Today
Incident Reporting Incident Reporting
A Proactive Approach A Proactive Approach
Janet MagnerJanet MagnerHealthcare ConsultantHealthcare ConsultantMagallan Risk ServicesMagallan Risk Services