Lessons Learned

Lessons Learned from Trends in the “Other” Safety Event Category

CHPSO recently completed an analysis of safety events submitted to the database in the first quarter of 2018 from the “Other” category of safety event reports. The “Other” category is one of the largest categories of events in the CHPSO database. It is designed for safety reports that do not fit into any of the eight categories as outlined by the Agency for Healthcare Research and Quality:

  1. Blood or Blood Product
  2. Device or Medical/Surgical Supply, including Health Information Technology
  3. Fall
  4. Healthcare-associated Infection
  5. Medication or Other Substance
  6. Perinatal
  7. Pressure Ulcer
  8. Surgery or Anesthesia (includes invasive procedure)

There were a total of 30,373 cases in the final sample and analysis of these data revealed 32 themes and issues. Four themes accounted for more than 50 percent of the total number of safety events. These were:

  • Behavior and Workplace Violence (4,446)
  • Expected and Unexpected Deaths, Codes, Rapid Response (4,008)
  • Leaving Against Medical Advice (AMA) or Left Without Being Seen (LWBS) (3,569)
  • Delay or Lack of Response (3,475)

The most common safety event reports involved behavior and workplace violence, representing about 15 percent of the events. These included reports of patients threatening, assaulting, and verbally abusing staff or peers and patients punching walls or damaging property. Other themes commonly overlapping this category included patients leaving or wanting to leave AMA, patients being classified as danger to self or others. Also included in this category were reports of inappropriate staff or provider behavior (e.g. rude, offensive, and unprofessional), as well as highly agitated or aggressive family or visitors.

The next most common theme (13 percent) involved cases of both expected and unexpected deaths, codes, and Rapid Response team calls. These included reports of patients having expired with or without additional descriptors. Reports of death after withdrawal of life support, as well as reports related to organ procurement following brain death, were also included in this category. In addition, there were also reports of rapid response calls, code blue, code STEMI (ST Elevation Myocardial Infarction), code stroke, code sepsis, and code airway.

Leaving Against Medical Advice (AMA) or Left Without Being Seen (LWBS) was the third largest category identified in the dataset, representing about 12 percent of the safety event reports. These cases often contained elements related to behavior or work place violence. Events involving patients requesting to leave or actually leaving AMA were often related to long delays in care. Wanting to go outside to smoke was also an issue associated with patients wanting to leave AMA. Some of the reports were associated with patients refusing to sign the required AMA forms.

Delay or lack of response was evident in about 11 percent of the cases. As mention above, many cases involved patients leaving AMA or becoming irate after long delays in care or testing. Other events involved delays potentially associated with severe harm or death. Delays were associated with a variety of other factors including: communication failures (e.g. critical values, codes, provider notification); lab studies; medication administration; lack of timely provider response; refusal to treat or assess patients; provider, staff, or bed availability, and delays in calling code or rapid response teams.

Facilities may want to consider reviewing data in this reporting category or look for trends and patterns within their organization as the “Other” category may provide insight into opportunities for improvement related to themes and issues such as those described above. The identification of which may provide the impetus for patient safety and quality improvement activities. CHPSO will provide a hospital-specific evaluation of member organizations that have submitted data into the “Other” category. Please contact CHPSO for more details.

The Hospital Quality Institute (HQI) offers many resources to assist organizations in coordinating and supporting patient safety and quality improvement activities. Click here for more information about HQI. CHPSO also offers a variety of free webinars throughout the year, some for members only and many that are open to the public. Click here for more information on upcoming CHPSO events. In addition, member organizations can learn from an analysis of their own event reports provided by CHPSO, as well as from one another by attending safe table discussions on a variety of topics throughout the year. Recent safe table topics have included Childbirth After a Prior Cesarean Delivery, Restraints, Disclosure and Early Resolution. Click here for more information on safe table meetings and here to see if your organization is a member of CHPSO.