Example Benefits of Good Incident Investigations. Mark Kinnear, CRSP Health and Safety Coordinator

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Scott Gilbert
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1 Example Benefits of Good Incident Investigations Mark Kinnear, CRSP Health and Safety Coordinator

2 Ross Memorial Hospital: Overview The Ross Memorial Hospital is an active, caring, community hospital, with a progressive team, dedicated to providing compassionate and quality patient care.

3 Ross Memorial Hospital: Overview Where: Located in Lindsay Capacity: 218 beds Serving: greater than 75,000 area residents Staff: over 850 full, part-time and casual staff Emergency Department: 43,000 + visits per year

75,000 area residents Staff: over 850 full, part-time

4 RMH: Health and Safety Overview RMH hired full-time health and safety professional in June 2008 prior to that; health and safety was covered as an additional responsibility for the existing human resources staff the existing health and safety system that was in-place was not very effective or responsive and was in need of significant improvements

for the existing human resources staff the existing health and safety system that was

5 Two Health and Safety Items Jumped Out at Me Right Away 1. Infection Control, Patient Safety and Health and Safety treated as separate entities To address these deficiencies and increase efficiency, these three groups started working closer together and working more collaboratively.

separate entities To address these deficiencies and increase

6 Two Health and Safety Items Jumped Out at Me Right Away Infection Control, Patient Safety and Health and Safety partnerships established.

7 Two Health and Safety Items Jumped Out at Me Right Away 2. Incident Investigations were not very effective in preventing repeat occurrences.

8 Traditional Incident Investigations

9 Traditional RMH Incident Investigations only WSIB incidents were being investigated very poor quality incident reports- especially in area of corrective actions reports often completed by employee with little or no supervisor involvement many repeat incidents (similar in nature) review of reports indicated that we were not visiting incident scene, interviewing all witnesses or tapping into all info sources

little or no supervisor involvement many repeat incidents (similar in nature) review of reports

10 Action Plan to Improve Incident Investigations 1. Obtain senior management support for system improvements to investigation program 2. Retool procedures / process for investigating incidents (in consultation with JHSC) 3. Develop and deliver in-house Incident Investigation training program 4. Health and Safety Review of all incidents and monitor improvement process

Retool procedures / process for investigating incidents (in consultation with JHSC) 3.

11 Example of Incident Investigation Improvement Location: Central Processing Department Incident Description: Staff member in CPD forwarded Near Miss to her manager and health & safety regarding scalpel blades left on the Emergency trays and then returned to CPD and thus creating a hazard to those working in CPD. On this occasions a blade was left in the scalpel handle and another blade was found in an iodine cup.

scalpel blades left on the Emergency trays and then returned to CPD and thus creating a hazard to those

12 Incident Description Scalpel blade left on tray.

13 Incident Description Scalpel blade left in iodine cup.

14 Incident Description Scalpel blade left in handle after use.

15 Exposed Sharp Hazard Incident Investigation CPD Response: CPD manager immediately completed investigation as to the details and source of the hazard. Corrective Actions: CPD Manager forwarded Near Miss on to Emergency Department Unit Manager regarding the hazards to her people when scalpel blades are left on trays and returned to CPD from the emergency department.

Corrective Actions: CPD Manager forwarded Near Miss on to Emergency Department Unit Manager

16 Exposed Sharp Hazard Incident Follow-up Emergency Department Response: ED Unit Manager immediately discussed the hazard and expectation to place all sharps into sharps containers with those who were working at the time and then forwarded to the remainder of her team via . e Additional Input from Nurses: Nurses informed us to make sure the physicians receive message as well because it is also their responsibility to put all of the sharps they use in the sharps containers.. (we were informed that doctors use sharps without nurses present).

17 Exposed Sharp Hazard Incident Follow-up Emergency Department Response: ED Unit Manager acted on this new information provided by the employee and the same concern regarding sharps was passed on to all emergency department doctors.

information provided by the employee and the same concern

18 Exposed Sharp Hazard Incident Follow-up Health and Safety Response: Provided internal consultancy role and thanked everyone for their input and quick response to address the hazard. Special public thanks given to nurses for the additional input.

everyone for their input and quick response to address the

19 Public Thanks Given to all Involved Thanks to all for their very professional response to correcting this potential hazard for our staff. It is refreshing to see all parties taking responsibility and taking the appropriate steps to correct hazards in a very timely manner, it is much appreciated. With all of your permission I would love to use this as an excellent example of internal responsibility and hazard correction in action in future training sessions. Thanks again, Mark

It is refreshing to see all parties taking responsibility and taking the appropriate steps to correct hazards in a very

20 Additional H & S Recommended Controls 1) Tracking System put in place. CPD staff instructed to immediately forward if sharps are returned to CPD. Tracking system put in place to trace back if person not meeting requirement so we can correct with them personally. That way we can provide an extra awareness talk or identify any repeat offenders.

Tracking system put in place to trace back if person not meeting requirement so we

21 Additional H & S Recommended Controls 2) Signage placed in area as an awareness reminder and to inform all who may have missed initial message. For Everyone s s Safety: Please remove all sharps (needles and blades) from instrument trays and place safely into Sharp s s containers

Managing the Care and Return to Work of Injured Workers (and controlling your Workers Compensation Costs)

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