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Our Disclosure Policy|
• To address the issue of the disclosure of serious events to residents/families.
• To create a comprehensive mechanism to identify, report, investigate, resolve and trend serious events without replacing professional judgment in resident care or administrative matters.
• To educate providers and residents/families concerning the many aspects of resident safety.
• To provide a consistent mechanism to improve the resident care process.
• To provide support mechanisms to residents, families, staff, and others affected by such incidents.
It is the policy of Algonquin Nursing Home to provide quality safe care to the residents of the home. Despite constant and committed efforts to provide and improve care in Ontario, on occasion patients are harmed rather that helped by health care. While sometimes these poor outcomes of care are unavoidable, at other times they result from preventable mistakes or errors in the provision of care. Algonquin Nursing Home analyzes such events and makes recommendations to prevent their recurrence. Algonquin Nursing Home is committed to respecting the rights of residents and their families to be informed about such events. Algonquin Nursing Home identifies and investigates all serious events and requires the full and frank disclosures of adverse events to residents.
Severity of Event:
Level 1: An event occurred but the resident was not harmed.
Level 2: An event occurred that resulted in the need for increased resident assessments but no change in vital signs and no resident harm.
Level 3: An event occurred that resulted in the need for treatment and/or intervention and caused temporary resident harm.
Level 4: An event occurred that resulted in initial or prolonged hospitalization, and caused temporary resident harm.
Level 5: An event occurred that resulted in permanent resident harm or near death event, such as anaphylaxis.
Level 6: An event occurred that resulted in resident death.
Levels 3 through 6 shall be discussed with resident, families/Substitute Decision Maker (SDM) and physicians.
In addition to the policy for “Disclosure of medication errors” which outlines a clear requirement for disclosure for registered staff to follow, there is also the Ministry of Health and Long Term Care Act legal requirement for disclosure of serious events.
Disclosure of serious and/or MOH CIS (Critical Incident Systems) events:
Occurrences that have resulted in harm and/or death to the resident must be disclosed/discussed with the resident/family/SDM and reported to the Ministry of Health and Long Term Care. Events for example like: unexpected admission to hospital, unexpected/expected resident death, unnecessary/erroneous treatment with burdensome impact on the resident.
If there is a question concerning disclosure, the event is to be discussed with the Director of Care and/or Administrator. Further inquiries will be directed to the Professional Advisory Committee’s Ethics Sub-Committee.
Disclosure to the resident/family/SDM and physician if required, should take place as soon as possible after a serious event has been recognized as having occurred.
Further investigation will determine which individual(s) should be present during the discussion. The responsibility may rest with the attending/advisory physician. The physician and the Director of Care may consider involving any one of, or all of the following: representatives from nursing, resident representative, allied health professionals, pastoral care, social workers or staff members known to and trusted by the resident/family.
The Administrator may have to identify the appropriate person to handle the disclosure.
Disclosure of an adverse event may occur face-to-face in a quiet, private place with adequate time set aside, avoiding interruptions. The results of the investigation of the event should be presented in a straightforward and non-judgmental fashion. An apology is required including expressing regret for what happened and concern for the resident’s welfare. Focus is to be on what is known at the time of discussion. Responsibility for the event must be taken. The attending physician may make a statement of responsibility to the resident and/or family. The physician and nursing home leaders acknowledge responsibility in their investigation for trying to find out the causes of the event, and further informing/updating the resident/family/SDM if required. Monitoring and managing any complications of the adverse event will be done if required. The nursing home will do whatever possible to improve systems to prevent similar events from happening to other residents.
The attending practitioner may, if warranted:
• maintain contact with the resident and/or identified family member
• provide further information, as appropriate, about the adverse outcome to the resident/family
• provide appropriate business cards and phone numbers to facilitate easy access to the physicians and/or principals involved.
All relevant information should be available to reference during the discussion. A summary of the disclosure and the attendees may be included in the resident chart. The attending practitioner, if involved may document all contact with the resident/family in the resident chart.
Caregivers might be affected, both emotionally and functionally, following an adverse event and disclosure.
A representative from the Resident Safety Department will notify department managers of staff involved in an adverse resident event for follow up with caregivers.
Support may include, but not be limited to:
• Peers or others with whom the caregiver can debrief.
• Instruction in documenting the event in the resident chart and appropriate forms.
• Advice from the attending/advisory physician on how to provide caregiver support in communicating with the resident and family.
Resolution and Observation
Corrective actions will focus primarily on processes, but human factors also will be considered.
Communication flow changes
Staffing adjustments as supported by funding
Revision of job descriptions
New/revised policies and procedures
Equipment changes as supported by funding
Work flow/structure/ergonomic changes
Educational training programs – revision; additional as supported by funding
Adjustment in duties, privileges or staff status
Employee improvement plan
Disciplinary and/or negligence follow ups
Recommendation and trending of events is an interdisciplinary approach managed by the Risk Management Committee. Trends are reported to the Professional Advisory Committee and may be presented to the Ministry of Health and Long Term Care, allied professional groups and Accreditation Canada during surveys.
It is the responsibility of all employees to be familiar and adhere to this policy and procedure.
Adverse Event: An injury caused by medical management rather than the resident’s underlying disease; also referred to as “harm”, “injury,” or “complication”. It is an undesirable outcome that the resident experiences resulting from error, mistake, incident, accident, or deviation from a standard of care that requires a documented change in clinical care.
Critical Incident System – Critical Incident Report
Long-term care homes are required to immediately complete an online Critical Incident Report to the Ministry of Health and Long Term Care on any of the following incidents:
• an unexpected or sudden death, including a death resulting from an accident,
• a resident who is missing for three hours or more,
• any missing resident who returns to the home with an injury or any adverse change in condition regardless of the length of time the resident was missing,
• an outbreak of a reportable disease or communicable disease,
• an injury in respect of which a person is taken to hospital,
• a medication incident or adverse drug reaction in respect of which a resident is taken to hospital.
The Ministry of Health and Long Term Care requires that the resident’s substitute decision-maker, if any, or any person designated by the substitute decision-maker and any other person designated by the resident to be promptly notified of a serious injury or serious illness of the resident, in accordance with any instructions provided by the person or persons who are to be so notified.
Disclosure: Providing information to a resident and/or Substitute Decision Maker about an incident
Error: An unintended act, either omission or commission, or an act that does not achieve its outcome.
Hazardous Condition: Any set of circumstances (exclusive of the disease or condition in which the resident is being treated), which significantly increases the likelihood of serious adverse outcome.
Near Miss: Any process variation that did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome.
Preventable Adverse Event: An injury (or complication) that results from an error or systems failure in the medical management of a resident. Examples: technical error during performance of a procedure, giving the resident a wrong medication, an error in decision-making, iv pump failure that causes a drug overdose, or failure of the system to communicate abnormal lab results to a physician who can act on the information.
Occurrence: An event that is not consistent with routine resident care or nursing home procedure which either did not or could have resulted in injury loss to a resident or visitor.
Serious Event: An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Unpreventable adverse event: An injury (or complication) that was not due to an error or systems failure and is not always preventable at the current stage of scientific knowledge.
This policy shall be distributed nursing home-wide and on the home’s web site.
See: Unusual Occurrence Report (ANH) Internal form
See: Critical Incident Systems (CIS) Ministry of Health and Long Term Care form
See: Error Form (ANH) Internal form
See: Adverse Drug Reaction/Drug Interaction Form (ANH) Internal form