Care - Adverse Events

Service: Risk Management
Subject: Care
Setting: Incident
Type: Risk Profiles

Reporting, learning from, and reducing adverse events and potential harm to patients is part of fostering safe systems of care and managing risk. Factors that may contribute to adverse events are organizational processes, training deficits, staffing levels and ineffective communication. This Risk Profile includes a variety of different types of adverse events in HIROC’s Risk Register as general category. Some examples may be related to accidental burns, allergic reactions/anaphylaxis (non-medication related), equipment related, and restraints/entanglement/entrapment. Additional risk profiles relating to specific adverse events are available such as:

Acuity                                                                Discharge/transitions                               Monitoring
Access                                                                Infection control                                       Falls
Communication/coordination                   Medication adverse events                  Security/assault

Key Controls/Mitigation Strategies

  • Policies / Procedures / Processes with Integrated Approach
    • Risk Management Program
    • Rapid escalation processes
    • Adverse events reporting policy with process for interdisciplinary event review. Including an algorithm for how event follow up can/should occur
    • Incident reporting systems and timely notification and communication of adverse events
    • Core incident reporting reviewer who monitors and closes all reports
    • Case reviews, incident debriefs, and/or root cause analysis
    • Disclosure policy
    • Patient Safety Initiatives 
      • Patient huddles, executive walk arounds, medication reconciliation, and patient safety and patient safety culture plan 
    • Patient and family engagement for quality improvement plans
    • Clinical rounding
    • Staffing skill mix assignment
    • Clinical practice guidelines and best practices from organizations developing standards, for example: regulated colleges or associations, Accreditation Canada, infection control organizations, safe medication practice organizations, organizations for health quality
    • Alignment of policies and procedures with accreditation standards
    • Electronic Medical Record Adoption Model (EMRAM)
    • Provincial collaboration education and policy development – participate with provincial committees related to sourcing and establishing best practices
  • Accidental burns
    • Safe kitchen process (beverages and food brought to patient at a specific temperature)
    • Wound Consultant to provide support and management of burns
  • Allergic reactions/anaphylaxis (non-medication related) 
    • Allergy lists and alerts, including “no known allergy” in the Electronic Medical Records
    • Single patient ID band that is colour coded if patient has allergies
    • ID band and allergy checks as mandatory elements of the nursing shift handover safety checks 
    • Signs alerting people to possible exposure to allergens (e.g., nuts in the kitchen), staff instructions/scripts for cooking classes
    • Prevention and management of latex allergy
    • Scent free policy
    • Anaphylaxis kit available on resuscitation cart and automated drug dispensing cabinets on unit
    • Allergic reactions monitored daily
  • Equipment related
    • Equipment replacement and maintenance policy
    • Equipment centralized with preventative maintenance program in place
    • Magnetic Resonance Imaging (MRI) safety labels of all equipment with: MRI safe, MRI conditional to a certain distance, and MRI “not safe” label. 
    • Keypad secured access to MRI environment
    • Annual MRI safety training
    • Stickers identify level of MRI training on ID badges 
    • Positioning sponges to avoid current, ensuring the alignment of electrical leads and body parts do not form a loop to allow a current to be generated
    • Compliance with Canadian Standards Association (CSA) standards for medical gas delivery systems and inhalation anesthesia
    • Construction or renovation involving medical gas pipeline systems verified by independent third party as per CSA standards
    • Routine maintenance and system checks of anesthetic equipment performed as per CSA standards
  • Restraints/entanglement/entrapment
    • Least Restraint Facility Policy with standardized restraint documentation 
    • Complete, timely documentation of rationale/need for restraint
    • Various modes of intervention strategies before use of restraints
    • Medication reviews, review use of chemical restraints
    • Education on other de-escalation techniques such as gentle persuasion
  • Education and Training
    • Family education materials prominent in clinical areas
    • Training on guidelines, procedures or policies 
    • Clinical teaching and coaching 
    • Develop educational plans based on required training per program area
    • Training in CPR, SBAR
    • Non-violent crisis intervention training within higher risk clinical areas
    • Skills drill code responses, annual refresher education, 9-911 approach
    • Communication escalation protocol
    • Required yearly education: patient safety module
    • Incident reporting and disclosure process
    • Clinical staff education regarding reporting in the safety learning system

Monitoring/Indicators

  • Patient safety culture survey
  • Numeric count of feedback/themes from daily or scheduled huddles 
  • Patient safety incident (and near miss) trending shared at quality committees and across organization
  • Patient/family complaint tracking
  • Staff engagement during patient rounds
  • Workplace violence incident report tracking 
  • Human resource indicators related to increase in absenteeism, transfers and resignations
  • Compliance audits (e.g., heath records, policies, mandatory education, documentation-allergy field completion, code cart checklist/stocking, use of restraints)
  • Key controls are monitored on dashboard (e.g., falls, falls risk assessments & care plans, % hospital acquired pressure injuries pressure ulcers & care plans, TOA completion, surgical safety checklist completion, medication reconciliation completion)
  • Ensure meaningful data for huddles, committees and Board Committees tracking
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.