In this section :

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:

Measure and monitor the types and frequency of these occurrences.
Use appropriate analytical methods to understand the contributing factors.
Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
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 for conducting chart audits and analysis methods are included in the Hospital 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) www.ahrq.gov

Never events [Internet]. Rockville (MD): The Agency; 2014 [updated 2019 Sept;]. Available from: https://psnet.ahrq.gov/primer/never-events

American College of Surgeons https://facs.org

National surgical quality improvement program. www.facs.org/quality-programs/acs-nsqip

American Society for Gastrointestinal Endoscopy https://www.asge.org/

Guidelines http://www.asge.org/publications/publications.aspx?id=352

American Society of Anesthesiologists. www.asahq.org
Association for Safe Aseptic Practice (THE-ASAP)

Asceptic Non-Touch Techniquie (Antt) http://www.antt.org
Aseptic non touch technique: The ANTT clinical practice framework. London; The-ASAP; 2015. http://www2.nphs.wales.nhs.uk:8080/WHAIPDocs.nsf/61c1e930f9121fd080256f2a004937ed/e4528983f2eddd3a80257f10003dd2f3/$FILE/ANTT%20Framework%20v4.0.pdf

Association of Perioperative Registered Nurses (AORN) https://www.aorn.org

Wrong site surgery.

Association of Surgical Technologists (AST) https:/www.ast.org/

Association of Surgical Technologists. Standards of practice for the decontamination of surgical instruments. AST; 2009. http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Decontamination_%20Surgical_Instruments_.pdf
Association of Surgical Technologists. AST standards of practice for packaging material and preparing items for sterilization. AST; 2009. http://www.ast.org/AboutUs/Sterilization_and_Disinfection/

Canadian Anesthesiologists' Society www.cas.ca

Guidelines. http://www.cas.ca/English/Guidelines

Canadian Association of Gastroenterology www.cag-acg.org

Guideline library.

Canadian Association of Interventional Cardiology http://caic-acci.org/
Canadian Blood Services - Professional Education https://professionaleducation.blood.ca/en

Clinical Guide to Transfusion. 2019. https://professionaleducation.blood.ca/en/transfusion/clinical-guide-transfusion
Bioburden Reduction and Control in Tissue Banking. Leading evidence based practice guidelines for: tissue recovery, microbial sampling, processing of musculoskeletal tissue, processing of cardiac tissue, processing of skin tissue. November 2016. https://professionaleducation.blood.ca/en/organes-et-tissus/pratiques-phares-et-directives-cliniques/tissus/bioburden-reduction-and-control

Canadian Medical Protective Association https://www.cmpa-acpm.ca/en

Canadian Medical Protective Association (CMPA), Healthcare Insurance Reciprocal of Canada (HIROC). Surgical safety in Canada: A 10-year review of CMPA and HIROC medico-legal data. CMPA, HIROC; 2016. https://era.library.ualberta.ca/items/7383e420-208b-4a5b-b4e7-525059a9af6d
Good practice guide. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/index/index-e.html

Canadian Patient Safety Institute

National Patient Safety Consortium. Never Events for Hospital Care in Canada. September 2015.

Canadian Society of Nephrology. https://www.csnscn.ca/committees/clinical-practice-guidelines/library
Canadian Standards Association (CSA) http://www.csagroup.org/

Blood and Blood Products and Cells, Tissues and Organ Transplantation. https://www.csagroup.org/store/search-results/?search=all~~Blood%20and%20Blood%20Products%20and%20Cells,%20Tissues%20and%20Organ%20Transplantation

Canadian Vascular Access and Association http://www.cvaa.info/
Centers for Disease Control and Prevention. www.cdc.gov

O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention; 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Difficult Airway Society https://das.uk.com/

Difficult Airway Society (DAS). Guidelines for management of unanticipated difficult intubation in adults 2015. DAS; 2015. https://www.das.uk.com/guidelines/das_intubation_guidelines

Gastrointestinal Endoscopy www.giejournal.org

ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force, Calderwood AH, Chapman, et al. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointest Endosc. 2014; 79 (3): 363-372. doi: 10.1016/j.gie.2013.12.015. http://www.asge.org/assets/0/71542/71544/4a572112-29a4-4313-8ab8-b7801e8f84e2.pdf
ASGE Standards of Practice Committee, Banerjee S, Shen B, et al. Infection control during GI endoscopy. Gastrointest Endosc. 2008; 67 (6): 781-790. doi: 0.1016/j.gie.2008.01.027. http://www.asge.org/assets/0/71542/71544/51E78060-CD85-4281-B100-6ABEBCB04C49.pdf
Reprocessing Guideline Task Force, Petersen BT, Cohen J, et al. Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update. Gastrointest Endosc. 2017; 85 (2): 282-294. doi: 10.1016/j.gie.2016.10.002. http://www.giejournal.org/article/S0016-5107(16)30647-2/fulltext

Infection Prevention and Control (IPAC) Canada. www.ipac-canada.org
Joint Commission www.jointcommission.org

The universal protocol for preventing wrong site, wrong procedure, and wrong person surgery^TM: Guidance for health care professionals. The Joint Commission; 2012. https://www.jointcommission.org/assets/1/18/UP_Poster1.PDF

National Health and Medical Research Council (NHMRC) www.nhmrc.gov.au

National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Commonwealth of Australia; 2019.
https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019

National Institute for Health and Care Excellence (NICE). www.nice.org.uk
Operating Room Nurses Association of Canada www.ornac.ca
Pennsylvania Patient Safety Authority http://patientsafety.pa.gov/

Patient safety topics – Wrong Site Surgery 2018. http://patientsafety.pa.gov/pst/Pages/Wrong%20Site%20Surgery/hm.aspx?psapst=Wrong-Site%20Surgery
Patient safety topics – Intubation. http://patientsafety.pa.gov/pst/Pages/Intubation/hm.aspx#
Yonash, R., &Taylor, M. (2020). Online Supplement to "Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities." Patient Safety. 2(4), i-x. https://doi.org/10.33940/supplement/2020.12.10
Pennsylvania Patient Safety Authority. Distractions in the operating room. Pa Patient Saf Advis. 2014; 11 (2): 45-52. http://patientsafety.pa.gov/ADVISORIES/Pages/201406_45.aspx
Pennsylvania Patient Safety Authority. Insight into preventing wrong-site surgery. Pa PSRS Patient Saf Advis. 2007; 4 (4): 109, 112-23. http://patientsafety.pa.gov/ADVISORIES/Pages/200712_109b.aspx

Public Health Agency of Canada. https://www.canada.ca/en/public-health.html

Public Health Agency of Canada (PHAC). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Ottawa, ON: PHAC; 2012. http://publications.gc.ca/collections//collection_2013/aspc-phac/HP40-83-2013-eng.pdf