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Selected Serious Events: Clinical And System Reviews, Incident Analyses

Given the broad range of potential causes of hospital associated selected serious events, clinical and system reviews should be conducted to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

1. Measure and monitor the types and frequency of these occurrences.
2. Use appropriate analytical methods to understand the contributing factors.
3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources forÌýconducting chart auditsÌý²¹²Ô»åÌýanalysis methodsÌýare included inÌýtheÌýHospital Harm Improvement Resource Introduction.

If your review reveals that your cases of selected serious events are linked to specific processes or procedures, you may find these resources helpful:

• Agency for Healthcare Research and Quality (AHRQ)Ìý
• Never events [Internet]. Rockville (MD): The Agency; 2014 [updated 2019 Sept;]. Available from:
• American College of SurgeonsÌý
• National surgical quality improvement program.Ìý
• American Society for Gastrointestinal EndoscopyÌý
• GuidelinesÌý
• American Society of Anesthesiologists.Ìý
• Association for Safe Aseptic Practice (THE-ASAP)
• Asceptic Non-Touch Techniquie (Antt)Ìý
• Aseptic non touch technique: The ANTT clinical practice framework. London; The-ASAP; 2015.Ìý
• Association of Perioperative Registered Nurses (AORN)
• .
• Association of Surgical Technologists (AST)Ìý
• Association of Surgical Technologists.ÌýStandards of practice for the decontamination of surgical instruments.ÌýAST; 2009.Ìý
• Association of Surgical Technologists.ÌýAST standards of practice for packaging material and preparing items for sterilization. AST; 2009.
• Canadian Anesthesiologists' SocietyÌý
• Guidelines.Ìý
• Canadian Association of GastroenterologyÌý
• .
• Canadian Association of Interventional CardiologyÌý
• Canadian Blood Services - Professional Education Ìý
• Clinical Guide to Transfusion. 2019.Ìý
• Bioburden Reduction and Control in Tissue Banking.ÌýLeading evidence based practice guidelines for: tissue recovery, microbial sampling, processing of musculoskeletal tissue, processing of cardiac tissue, processing of skin tissue. November 2016.
• Canadian Medical Protective AssociationÌý
• Canadian Medical Protective Association (CMPA), Healthcare Insurance Reciprocal of Canada (HIROC).ÌýSurgical safety in Canada: A 10-year review of CMPA and HIROC medico-legal data. CMPA, HIROC; 2016.
• Good practice guide.Ìý
• Canadian Patient Safety Institute
• National Patient Safety Consortium. Never Events for Hospital Care in Canada. September 2015.
• Canadian Society of Nephrology.
• Canadian Standards Association (CSA)Ìý
• Blood and Blood Products and Cells, Tissues and Organ Transplantation.Ìý
• Canadian Vascular Access and AssociationÌý
• Centers for Disease Control and Prevention.Ìý
• O'Grady NP, Alexander M, Burns LA, et al.ÌýGuidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention; 2011.
• Difficult Airway SocietyÌý
• Difficult Airway Society (DAS).ÌýGuidelines for management of unanticipated difficult intubation in adults 2015. DAS; 2015.Ìý
• Gastrointestinal EndoscopyÌý
• ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force, Calderwood AH, Chapman, et al. Guidelines for safety in the gastrointestinal endoscopy unit.ÌýGastrointest Endosc. 2014; 79 (3): 363-372. doi: 10.1016/j.gie.2013.12.015.
• ASGE Standards of Practice Committee, Banerjee S, Shen B, et al. Infection control during GI endoscopy.ÌýGastrointest Endosc.Ìý2008; 67 (6): 781-790. doi: 0.1016/j.gie.2008.01.027.
• Reprocessing Guideline Task Force, Petersen BT, Cohen J, et al. Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update.ÌýGastrointest Endosc.Ìý2017; 85 (2): 282-294. doi: 10.1016/j.gie.2016.10.002.
• Infection Prevention and Control (IPAC) Canada.Ìý
• Joint CommissionÌý
• The universal protocol for preventing wrong site, wrong procedure, and wrong person surgery^TM: Guidance for health care professionals. The Joint Commission; 2012.
• National Health and Medical Research Council (NHMRC)
• National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Commonwealth of Australia; 2019.
  
• National Institute for Health and Care Excellence (NICE).
• Operating Room Nurses Association of CanadaÌý
• Pennsylvania Patient Safety AuthorityÌý
• Patient safety topics – Wrong Site Surgery 2018.
• Patient safety topics – Intubation.
• Yonash, R., &Taylor, M.Ìý (2020).Ìý Online Supplement to "Wrong-Site Surgery in Pennsylvania During 2015–2019:Ìý A Study of Variables Associated With 368 Events From 178 Facilities." Patient Safety. 2(4), i-x.
• Pennsylvania Patient Safety Authority. Distractions in the operating room.ÌýPa Patient Saf Advis. 2014; 11 (2): 45-52.
• Pennsylvania Patient Safety Authority. Insight into preventing wrong-site surgery.ÌýPa PSRS Patient Saf Advis. 2007; 4 (4): 109, 112-23.
• Public Health Agency of Canada. Ìý
• Public Health Agency of Canada (PHAC).ÌýRoutine practices and additional precautions for preventing the transmission of infection in healthcare settings. Ottawa, ON: PHAC; 2012.
• Public Health OntarioÌýÌýÌý
• .
• Royal College of AnaesthetistsÌýÌý
• Safety, standards, and quality.
• World Health Organization (WHO)Ìý
• WHO guidelines for safe surgery: Safe surgery saves lives 2009. Geneva: WHO; 2009.