Craig R. Sellers

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

Background Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution. Methods All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated. Results 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs. Conclusions This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.

HIV/AIDS in Older Adults: A Case Study and Discussion

Infection associated with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in older adults is an increasing problem in clinical care. Often regarded as a disease of the young, more than 10% of HIV infection actually is found in people 50 years of age and older. In addition, individuals with HIV and AIDS are living longer. Approximately 71% of them currently are in their 30s and 40s. Given the current therapies available, it is conceivable that these patients will live well into their 60s and beyond. A case study describing the acute care experience of a 77-year-old African American man is reported. Pitfalls of diagnosis and management are discussed in relation to the care of an older person with HIV disease. The epidemiology of HIV in this population and a review of some recent literature and research on HIV and older adults are presented.

Patient Perspectives on Accessing Acute Illness Care

Introduction Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs. Methods We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews. Results The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses. Conclusion Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs’ capabilities, and enhancing EDs’ resources to care for older patients.

Process Variances in Older Adults’ Care Transitions from Emergency Department to Home: Process Breakdown Versus Process Resiliency

Introduction For many older adults, the process of going to the Emergency Department (ED) and coming home to access care in the community is a frequent and high-risk occurrence. These transitions have been shown to be a vulnerable and risk-prone period. The process remains a critical patient safety challenge despite efforts to improve these transitions. Part of the problem is that an ED transition is thought of as a single episode of care rather than a sequential, but often cyclical process. Conceptualizing the ED care and transitions as a longitudinal process, rather than a onetime episode, will provide insight as to how to improve care transitions of older adults by studying the process as it actually occurs from a patient’s perspective. Further, variances will be examined to see what leads to a successful or unsuccessful process. Methods A secondary analysis was conducted on interview data from older adults (age ≥ 65 years) that had been discharged from the ED in the past 30 days. A loosely structured interview guide was used to encourage participants to describe their complete “patient journey”. The content analysis was directed by the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework to analyze the processes that can result in various outcomes that are positive, negative, or neutral. The coding scheme included the six SEIPS 2.0 elements: Person, Organization, Task, Tools & Technology, Physical Environment, External Environment, and Process, and was developed with the goal of identifying process variances and coding those variances along with associated sociotechnical system elements. Results Results revealed three critical aspects related to the process of older adults’ transitions to and from the ED: (1) older adults often experienced a cyclical process that ended with them being readmitted to the ED for the same concern; (2) process variances to the expected ED care transition paradigm led to either a complete process breakdown or a successful execution of the process; and (3) breakdown or successful execution of the ED care transition depended on how the sociotechnical system responded to process variances. Discussion Our results suggest that for older adults, transitions to and from the ED do not follow the expected linear ED care paradigm. The ED transition process is variable and the success of the process is dependent on the sociotechnical system. The ED care transition process variances experienced by older adults have the potential to inform the design of transition interventions. Care transitions to and from the ED were not an episodic occurrence as they have previously been conceptualized. Rather, ED care transitions happen longitudinally, extending beyond the ED and into the community, and have a myriad of variances that can occur. Currently, many interventions to improve ED transitions focus specifically on the discharge process (i.e., an episodic conceptualization), and fail to address potential antecedents to process failures as well as downstream sociotechnical system factors that could affect the success of the care transition

Who Is Attending? End-of-Life Decision Making in the ICU (318-C)

Who Is Attending? End-of-Life Decision Making in the ICU (318-C) Judith Baggs, PhD RN FAAN, Oregon Health & Science University, Portland, OR. Madeline Schmitt, PhD RN, University of Rochester, Rochester, NY. Thomas Prendergast, MD, Portland VA Medical Center, Portland, OR. Sally Norton, PhD RN FPCN, University of Rochester, Rochester, NY. Craig Sellers, PhD RN ANP-BC GNP, University of Rochester, Rochester, NY. Jill Quinn, PhD RN CS-ANP FNAP FAHA FAANP, University of Rochester, Rochester, NY. (All authors listed above for this session have disclosed no relevant financial relationships with the following exception: Baggs is an editor for Wiley-Blackwell Publishers and receives an honorarium.)