Client Safety Committee Annual Report April 2015

Transcription

1 Client Safety Committee Annual Report April 2015 Submitted by: Steve Dawn Manager Behavioural Residential Services Chair, Client Safety Committee

2 History, Mandate and Responsibilities The Client Safety committee (previously known as the Patient Safety committee) was struck in November The committee s mandate is to review issues related to medication errors, client incidents and accidents, client falls, Pro Re Nata (PRN) medications, adverse events, quality improvement, organizational culture, root cause analysis, ensure compliance with the standards and required organizational practices (ROP s) identified by Accreditation Canada, and, generally, advise the executive director on matters related to patient safety within the agency. The committee meets, at a minimum, quarterly to discuss and review all issues related to patient safety and make recommendations, where appropriate, to the executive director for remedial action. Committee Composition The committee is comprised of: Permanent members: Chair Manager behavioural residential services Chief Executive Office or designate Manager, clinical programs One Safe Management advanced instructor One behavioural therapist One medication coordinator Members with a two year terms and the option of extending for two years: A minimum of one direct care staff from each residential service A minimum of one direct care staff from group/outreach services Committee Activities and Goals During the past year the committee was involved in a number of activities to enhance and improve patient safety within the agency.

3 Culture Committee members again focussed on enhancing the culture of client safety in the organization. Client safety presentations were developed for new staff during orientation and training. This was completed four times during the year and has become a standard orientation and training presentation. The committee also ensured that medication errors and the topic of client safety in general was a standing agenda item in all service meetings. During November select client safety committee members and the chair of the committee attended individual service meetings and to discuss the importance of disclosure and adverse events. During National Patient Safety Week, October 25- November 1, 2014, the client safety committee scheduled activities to raise awareness and knowledge of client safety. Client safety word searches and games were distributed daily to services. Services submitted their answers were awarded prizes during the December joint staff meeting and staff presented videos or poster presentations featuring clients to highlight client safety activities within their services. Good Catch Identification Over the course of the year awards were presented to the staff that identified near misses and hazards, or good catches, within the agency that had the potential to cause harm. There were a total of 105 good catches identified by staff with the annual target being 100. Good Catch of the Year Annually a good catch of the year award and plaque is presented to the good catch which was determined to have the most impact. Kelsey Warnick, Transitional Living Services, was awarded the Good Catch of the Year. Kelsey smelled something burning in the hallway of the TLS building. The TLS apartments are on the 14 th floor. Kelsey found that the odour or smoke was coming from an apartment that did not belong to a client. Kelsey knocked on the door of the apartment and woke the resident. The individual had fallen asleep while cooking. Kelsey s quick thinking resolved a dangerous situation that could have involved many people.

4 Client Incident/Accidents During the fiscal, the data collected on client incidents and accidents indicated that the majority of accidents were due to client physical aggression and environmental aggression. The majority of incidents or near misses were related to client verbal aggression, environmental aggression and medical concerns. This was consistent with the findings from , and The data again indicated that the majority of the incidents and accidents occurred at the residences in the Vineland and Niagara area. These residences are structured specifically to serve more challenging clients. Adverse Event identification A change made in with respect to the identification of adverse events was introduced and used by the managers when evaluating the incident and completing client hazard incident accident reports. The information is analyzed regularly by the client safety committee and brought to the management team for remedial action where necessary. There was a decrease in adverse events in comparison from to Medication Management Over the course of the year the committee tracked and reviewed medication errors and the reasons for errors made by both clients and staff. The most prevalent client errors were refusals, while the majority of staff errors were documentation errors. Education with respect to medication administration occurred throughout the year. With these efforts there has been a decrease in documentation errors. This finding is consistent with the findings from , , and Prospective Risk Analysis (PRA) A core team of the Client Safety committee, the Joint Occupational Health and Safety Committee, and management completed a prospective risk analysis concerning the risks associated with transporting a behavioural client in the agency van. The risk analysis reviewed the steps required for staff to identify the risk, assess the situation, communicate with the team, and follow policies that are in place. The document outlines a variety of steps in identifying potential risk. The prospective analysis involved: Conducting a thorough task analysis of the activity

5 Evaluating the risk of each step in the task analysis based on the frequency with which an error could occur and the severity of the error Developing plans to deal with the risk The core team included: Brandi Pilkington, Kendra White, Amanda Iuglio, Steve Dawn, and Candy Sarraf Several policies, procedures and training were in place to address the above; however, after completing this process the committee identified actions to be completed. They included: Review agency van training to capture steps of the PRA Include in monthly inspection the van insurance is in the vehicle and on weekly van inspection a statement on the checklist re: verifying van supplies are appropriate, stocked and secured Client Safety Committee Goals The following provides a summary of the committee s goals and performance for as well as the goals and indicators for the fiscal. Client Safety Committee Goals for Goal Indicator Result To have a positive patient safety culture within the organization Promote client safety 90% on the Client Safety Culture Tool 93% Medication errors and process as a standing agenda item at all administrative service meetings Complete Promote client safety Client Safety as a standing agenda item at all client related service meetings. November 2014 presentation to staff around adverse events, disclosure and sentinel events Complete Complete

6 Client Safety Committee Goals for Goal Create a culture of client safety in the organization Indicator 90% score on the Accreditation Canada Client Safety Culture Tool Implement Root Cause Analysis process for medication administration errors that result in a level 2 adverse event June 2015 Implement Root Cause Analysis process for falls resulting in medical treatment where staff are involved. June 2015 Add Root Cause Analysis training into O&T at Medication training session Nov 2015 Promote Prospective Risk Analysis within the agency and at services Sept 2015 Other goals related to patient safety are articulated in the organization s Quality Improvement Plan.