One unwanted issue that is common with Critical Incident monitoring systems across healthcare is errors of omission. These are errors that occur as a result of a step not taken or when an appropriate step is left out of a process. Omissions represent a primary cause of preventable morbidity and mortality within patient care systems.
In many of these instances of omission, the greatest concern is that the assigned clinician has often been alerted that a significant event could occur, but they do not take preventative action. The most common reasons that alerts fail are that staff often don’t:
§ process the alerting information fully.
§ attend to the information timely.
This “alert fatigue” may result because:
§ alerts highlight events that the staff person already knew and considered inconsequential.
§ staff have become desensitized to the acuity of our clients.
There have been multiple trainings on the how, when, where, what, and why related to submitting an electronic critical incident report as well as your responsibility to complete a Risk Assessment each time you are with your clients. Both the e-CIR and Risk Assessments are tools you can use in developing your care approach with your client. For example, both provide you with information about client issues and can serve as a comparison instrument providing you with snapshots at various points over an expanse of time. This article elaborates on the duty of care we have when our clients find themselves in situations that cause concern. Consider and contemplate the following tips as they apply to your approach to the care of your clients:
Continue to complete the e-CIR and conduct risk assessments. Gain a thorough knowledge of the circumstances of each episode of risk that develops with your clients. This information will help you develop needed interventions and you will begin to put together your own “alerts” or early warning signs.
Be alert to the possibility of hidden information. Risk assessments of some individuals may involve a high probability of deception (i.e., substance use, criminal activities). Clinicians need strategies, skilled interviewing techniques, and examination/analysis of clinical information to assist them in helping their clients. It is, quite simply put, a matter of careful listening and strategic questioning, which serves to help clients resolve their risk issues.
Ensure all health and safety issues are in the individual’s POS. This will assist in structuring your care and prompt specific interventions.
When many medical issues are present - get a medical staff involved. Request a Nursing Consult for your client and keep the RN informed about any changes in their health status.
Be diligent in watching for medication changes. Make sure you increase your monitoring and keep the RN and prescriber informed when your client has had a medication change. The CMs/SCs are valuable eyes and ears for doctors and nurses.
View intensity of treatment and frequency of contacts as dynamic and flexible. The intensity of provided services should be continually adjusted to meet risk needs and the severity of illness for our clients. Do not arbitrarily determine intensity without regular re-assessments to evaluate the appropriateness of the care given.
Consciously monitor how long you are allowing a client to remain in a “risky” situation. Do not allow “negative” circumstances (refusing medical treatment, substance use/abuse/misuse, binging, unsafe living situations etc.) to continue for weeks or months. Limit the time before you will intervene with a petition, an ATO, or other assertive actions.
Show due diligence. Do not hesitate to conduct outreach. If you have not seen or heard from a client, make a concerted effort to locate him or her, and document all your attempts.
Match the aggressiveness of your response and interventions to the level of risk represented by the client's symptoms/behaviors. Meet with the treatment team and your supervisor regularly on cases that are high-risk.
Watch ATO renewal dates. ATOs can be one of your most effective tools. Do not let them expire unless they are no longer needed.
Monitor treatment transitions vigilantly. Transitions in level of care, to a new program, or to a new clinician, can create risk in your clients, especially during the hand-off of cases and to the clinician-to-clinician transfer that occurs within a program.
Meet the face-to-face requirements of your client’s IPOS. If the treatment frequency requirements of the IPOS have not been met, make sure you have provided an explanation in the record. Document all your attempts.
Remember that the GHS service array acts as a vast safety net for our vulnerable clients. That safety net is formed by the interweaving of all of our skills, abilities, interventions, communications, compassion, and caring. It depends on our professional support of each other and toward every individual that we serve. All staff should be watchful of the clients in our buildings, even if that individual is not your direct responsibility. If we do not do our part for all of our clients, the resulting “holes” in the net can lead to dreadful outcomes. We must be vigilant in recognizing alerts so that negative outcomes are minimized and, wherever possible, eliminated.
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