BEGIN:VCALENDAR VERSION:2.0 PRODID:Linklings LLC BEGIN:VTIMEZONE TZID:America/Chicago X-LIC-LOCATION:America/Chicago BEGIN:DAYLIGHT TZOFFSETFROM:-0600 TZOFFSETTO:-0500 TZNAME:CDT DTSTART:19700308T020000 RRULE:FREQ=YEARLY;BYMONTH=3;BYDAY=2SU END:DAYLIGHT BEGIN:STANDARD TZOFFSETFROM:-0500 TZOFFSETTO:-0600 TZNAME:CST DTSTART:19701101T020000 RRULE:FREQ=YEARLY;BYMONTH=11;BYDAY=1SU END:STANDARD END:VTIMEZONE BEGIN:VEVENT DTSTAMP:20240325T185834Z LOCATION:Salon A-3 DTSTART;TZID=America/Chicago:20240325T140600 DTEND;TZID=America/Chicago:20240325T142400 UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i n Health Care_sess122_INDLEC183@linklings.com SUMMARY:Implementation of Systemic Contributors and Adaptations Diagrammin g for Event Review DESCRIPTION:Oral Presentations\n\nNikoleta Kolovos (Washington University School of Medicine in St. Louis)\n\nMany patient safety events do not meet the criteria for formal hospital review but impact ongoing safety efforts at the unit level, frequently revealing weaknesses in the local system th at put patients at risk. Concise review of these events is likely to stren gthen the overall system of care delivery, but individual hospital units m ay not be sufficiently resourced to undertake standard retrospective event analysis techniques. To meet this need, we have piloted the introduction of an alternate method of event review in the Pediatric Intensive Care Uni t (PICU): Systemic Contributors Analysis and Diagram (SCAD) (Jefferies et al., 2022). First utilized by the National Aeronautics and Space Administr ation (NASA) following a near-miss event in 2013, SCAD identified multiple contributors to a near-fatal event not evident in the RCA performed for t he event (Walker et al., 2016). In our PICU, the SCAD technique focuses on identifying pressures in the critical care delivery environment that lead to conflicts and adaptations that contribute to patient safety events. Pr oponents of this methodology seek to collaborate with Washington Universit y School of Medicine and St. Louis Children’s Hospital to deploy this tool to both promote safer healthcare and advance the field of human factors a nd resilience engineering.\n\nSimilar to many hospitals, when a serious sa fety event occurs at St. Louis Children’s Hospital, hospital leaders partn er with the unit and proceed with a standard retrospective event analysis, such as an Apparent Cause Analysis (ACA) or a Common Cause Analysis (CCA) . For sentinel events, a Root Cause Analysis (RCA) is performed as require d by The Joint Commission. RCAs provide structure but may expend considera ble resources. These hospital-level event analyses require in-depth chart review and scheduling at least one meeting with multiple individuals invol ved in the event. Units also define specific triggers for patient safety e vent review, which may include mortality, return to a higher level of care within 24 hours, or unplanned procedures. These triggers do not usually r equire hospital-level involvement, but unit-based patient safety specialis ts expend significant effort creating timelines, reviewing charts, and faci litating meetings. Regrettably, staff and other resource shortages increas ingly constrain the number of events to undergo analysis at all, putting t he organization at further risk. \n\nIt is not uncommon for RCA, ACA, and CCA action items to include those of low to intermediate strength, as desc ribed by the National Patient Safety Foundation (NPSF) (2015). The NPSF al so notes that recurrence rates may result from intermediate- or weaker-str ength action items that focus more on human memory versus actions that tak e a system-based approach (2015). Following the implementation of many RCA , ACA, and CCA interventions at our institution, we find that events of th e same type do regrettably recur. While unfortunate, this phenomenon is no t unexpected, as the long-term impact on event recurrence is not clear wit h the use of RCAs (Kellogg et al., 2016; Wu et al., 2008). Peerally and co lleagues (2016), studying the sentinel events most commonly reported to th e Joint Commission (falls, wrong-side or wrong-site surgery, and retained foreign objects), noted that while these events occur infrequently, they m ay indeed recur in the same institution.\n\nWhile SCAD reviews do not repl ace hospital-level work via RCAs, ACAs, or CCAs at our institution, we fin d that the SCAD analysis approach offers the PICU several advantages, incl uding ease of scheduling—a core team performs the work during an establish ed time; less preparation work required as the process is a facilitated di scussion; events analyzed are those not typically reported to the Joint Co mmission; more open discussion—less focus on the individual and more on th e environment. \n\nThe core SCAD analysis team, consisting of Pediatric Cr itical Care Medicine faculty, patient safety specialists, and fellows, hav e used the SCAD tool to review nineteen patient safety events in our PICU. The SCAD process consists of a one-hour facilitated discussion where the SCAD diagram projects on a whiteboard, whereupon open commentary is encour aged in a blame-free environment. Beyond the eleven mortality or cardiopul monary resuscitation events and two patient morbidity and care escalation events, the remaining events offered opportunities to explore care system processes that did not cause patient injury but were at risk for recurrenc e and could result in future harm. Facilitators also use SCAD to promote d iscussion around decision-making removed in space and time from the event as well as endemic blunt-end forces in the system. The core SCAD analysis team develops action items following the discussion and helps facilitate t heir implementation. \n\nWe will share a case study of a SCAD analysis com pleted when a nurse inadvertently administered an intravenous medication o rally. While the patient experienced no harm, the review uncovered medicat ion practices unknown to most bedside staff. The SCAD diagram afforded ins ight into multiple systemic contributors to the event. These insights, whi ch are qualitatively different than those afforded by RCAs, include how ti me pressure interacts with the unit’s reliance on the IV team, considerati ons regarding sucrose and breastmilk, sources of expertise sought out by n urses, and challenges using the medication-dispensing machine requiring pr eviously unappreciated staff adaptations.\n\nJefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic impl ementations. Proceedings of the 66th Annual International Meeting of the H uman Factors and Ergonomics Society, 66, 75–79. \n\nKellogg, K. M., Hettin ger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., & Fairbanks, R. J. (2016). Our current approach to root cause analysis: Is it contribu ting to our failure to improve patient safety? BMJ Quality & Safety, bmjqs -2016-005991. \n\nNational Patient Safety Foundation (NPSF). (2015). RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. National Patie nt Safety Foundation. https://www.ihi.org/resources/Pages/Tools/RCA2-Impro ving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx\n\nPeerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2016). The problem with root cause analysis. BMJ Quality & Safety, bmjqs-2016-005511. \n\nWalker, K. E. , Woods, D. D., & Rayo, M. F. (2016). Multiple Systemic Contributors versu s Root Cause: Learning from a NASA Near Miss. Proceedings of the Human Fac tors and Ergonomics Society Annual Meeting, 60, 264–264. \n\nWu, A. W., Li pshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685–687.\n\nTrack: Patie nt Safety Research and Initiatives\n\nSession Chairs: Hanna J Barton (Univ ersity of Wisconsin - Madison) and Asfand Khan (Embry-Riddle Aeronautical University, AdventHealth) END:VEVENT END:VCALENDAR