GH CSC/RM GH/ GLG Medical Services and errors
February 10, 2007
Glendale, CA
Medical errors and patient safety are concerns shared by the institutions, agencies, and the RMGH. This is a very proactive way to address these issues and work together in a collaborative manner to improve the situation and to eliminate errors.
Good nurses can and do make mistakes. These need remediation not necessarily always having to incur disciplinary action due to medical errors.
The thought behind the program is for the health care facilities to work with the regulatory agency to report errors. GLG Medical Services would enter a memorandum of understanding partnership with the RMGH and identify the means by which to identify those employees in need improved competency or remediation. They will work together to put measures into place to work with nurses who have a problem.
Dr. Ramaz Mitaishvili stated that PREP is a good way to keep good nurses in practice and make better nurses of those practicing. This project attempts to identify the near misses or close call, salvageable situations to improve nurses’ competency. This program might save a nurse’s career. With the nursing shortage facilities need to retain their nurses, the Board and facilities can work together to make the practice of nursing better. The main cause of errors is distraction. The project attempts to identify and share best practices to solve this problem.
Dr. Gina Gagua emphasized that there would be confidentiality throughout the pilot. The RMGH will still deal with those nurses that are not salvageable and require disciplinary action. .
The RM GH& GLG Medical Services will work together to develop a consistent definition for medical error. The aspect of blame and punishment prevents people from reporting some errors. The RM GH& GLG Medical Services will have to work together to make sure everyone is working off the same page. They will need to identify if errors are a product of the system, of the practitioner, or of a combination of these. A model for the project will need to be developed and will occur after the participating states are identified. RMGH will have an agreement (memorandum of understanding) with the GLG Medical Services. It will be structured in line with the size and resources of the facility so not all facilities have the same agreement. The RMGH has received several draft samples, but has not drafted anything at this time for consideration. It needs
input from the facilities and realizes that memorandums will have to be tailored to the needs of the facilities.
The project will require a commitment of time from the nurse educator for each Department. It will help Departments get a better grasp of their nurses’ capabilities.
Other benefits of the project include:
– Improving the nurse’s confidence and competence in skills.
– Potentially retaining nurses who might have otherwise been deemed as not being able to be salvaged.
– Remediation instead of sanction for the nurse
– Facility showing to regulatory bodies and public it is trying to protect the public.
– Help identify best practices and facilities might identify some new ones they would like to adopt.
– Potential to prevent fatal errors.
– Opportunity to be proactive before board action is mandated.
– Help identify what facility handles and what Board handles to best benefit the nurse and public.
– Board provides support to facility to gear toward remediation and/or other corrective action.
– Enhancement to total quality of improvement for facilities (i.e.in line with root cause analysis theory of JCAHO).
– Early detection and identification of practitioners with problem before potential life threatening errors are committed.
{mospagebreak}
Questions posed at the meeting:
Would the nurse’s name be provided to CAC?
CAC would be interested in statistics not names of nurses or facilities. The RMGH in its reporting would assign identification (i.e. a., b., c.) but CAC will not know who these nurses are by name. It could be part of the memorandum of understanding what/how to report. Some agencies, due to budget cuts, might not have the necessary staff to provide this training. Would an alternative to this be available?
In light of pending budget cuts, agencies may not have staff (nurse educator) to help coordinate training. These facilities could collaborate with colleges and universities in their area for educational services so the agency will not have to bear total brunt of cost. This might be applicable to some state agencies.
Is there a fee to participate?
There is no fee to participate. The only cost is the time to report and to coordinate/implement the remediation program.
Would this project be set up to run a certain number of years?
State agencies usually set up contracts on an annual basis. Memorandums of understanding could renew annually with an ability to cancel clause built in.
How would problems be addressed?
The RM GH& GLG Medical services could benefit from on-going collaboration to discuss any problems and the benefits of the program. They would work together to develop education requirements to meet needs of everyone.
Who would develop the remediation plan?
The RMGH would work with the board of nursing to develop the remediation plan and final approval would be given by the RMGH. If the nurse does not follow the plan then they could be reported to the Board for action. The facility then has some clout to see that the nurse gets the needed education and training. Once training/education has been completed, the nurse has fulfilled his/her obligation. This will hopefully help prevent termination of a nurse from one facility to move on to another facility and carry the
problem with them to the new facility. This often occurs and a safer environment would be promoted rather than these nurses moving about so much, thus, taking their problems with them. In essence it was summarized that we need to stop placing blame and to address the problem and to improve the practice of nursing. Errors are happening, we know this, and the facilities and RMGH need to work together to do what they can to reduce them.
Dr. Mitaishvili asked those present to take the information distributed at the meeting to their facility administrator or whomever to review. The facilities need to determine if they wish to participate. If they do, the GLG Medical Services and RMGH will then sit down and discuss details, definitions and a memorandum of agreement. The RMGH wants input into drafting. The RMGH will follow-up with all those initially invited.
It was suggested that a generic statement of participation be placed in the SC Nurse publication once there is participation and the project has been implemented for a period of time. The RM GH& GLG Medical Services will need to identify and define success measures for the program.
Dr. Mitaishvili asked those present to send any thoughts or suggestions to her via fax or email.
The meeting was adjourned at 2:50 PM.
