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Don’t be averse to addressing adverse events

Ambulatory Safety Monitor, February 10, 2005

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Adverse events affect not only patients and their immediate caregivers, but all levels of personnel, says Joan Riebock, senior director of program operations at the AAAHC.

Two years ago, the accreditor established standard 2.B.22, which calls for the governing board to "establish processes for the identification, reporting, analysis, and prevention of adverse incidents and ensuring their consistent and effective implementation by developing a system." Put proper policies and procedures in place to ensure that you stay in compliance with this important standard, Riebock says.

Reiterating a significant topic

Other standards throughout the accreditation manual reflect and support the importance of 2.B.22. For example, standards 3.B.6 and 5.III.B.4 reiterate the necessity to review, analyze, and take responsibility for compliance with adverse incident reporting. Chapter 3 requires that the administration and governing board actively take part in the adverse reporting system.

The AAAHC suggests interviewing personnel to see whether policies and procedures are understood and practiced. In Chapter 5, organizations find that reporting is critical to an effective risk management program as well. Facilities should identify each person's responsibility in the program, including roles in adverse event reporting.

The new AAAHC standard 3.A.15 also reflects the importance of adverse incident reporting. It requires documentation of adequate orientation and training to familiarize all personnel with the organization's policies, procedures, and facilities.

"The idea of appropriate orientation training of all personnel is a good example of establishing a process," Riebock says. Previously found in Chapter 7, Professional Improvement, the AAAHC will move this standard to the more appropriate Administration chapter in the 2005 Accreditation Handbook for Ambulatory Health Care.

Start with definitions

Don't let this standard-or any standard-intimidate you. Start with definitions appropriate to your facility. Although the AAAHC includes guidance for identifying, reporting, analyzing, and preventing adverse events, it's not an exhaustive list, Riebock says.

When creating a system, ask the following questions:

• What is an adverse incident in my facility?
• What plans do I already have in place to report events?
• Do those plans reflect my processes?

When defining adverse incidents, divide them into two categories: administrative and clinical. Administrative events include breach of confidentiality of patient information, and clinical events may involve wrong-site surgery, medication errors, or falls. Riebock says that when AAAHC surveyors find compliance deficiencies with this standard, they can usually trace it back to the organization's failure to define an adverse incident.

Failure to identify an adverse incident in your facility demonstrates an all-around lack of education about the system, says Riebock. "The adverse reporting system should be a part of your new staff orientation," she says. "You should also make sure that all staff are knowledgeable on the subject." And finally, she says, it is critical that analysis of events takes place at a higher managerial level.

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