Sign In
CPSI Share                                              
10/16/2012 6:00 PM

​​The foundation begins with an apology 

Claire Smith was only 10-years-old when she unexpectedly died in a Pediatric Intensive Care Unit (PICU).   Claire died following a planned surgery to correct a malformation at the base of her brain which was causing her spine to erode and curve significantly, and a myriad of other severe neurological signs and symptoms.  Claire’s tragic death was ultimately attributed to serious issues in care and in the system. Her parents, Raeline McGrath and David Smith, openly talk about what happened, not to find fault, but rather to bring about positive systemic and cultural change.

Raeline and David asked for and then invited to participate in an external analysis of Claire’s death. The analysis team met with them first to learn from their perspective before interviewing others. When the findings were about to be released, the process was structured to have the report shared with Claire’s parents first.  The meeting opened with an apology and that formed the foundation for the post-analysis disclosure about what happened, how and why it happened and what will be done to make care safer. “For us as Claire’s parents, it acknowledged our place in the process,” says Raeline. 

“The analysis process was objective, thorough, accurate and startlingly candid which enabled us to have an open, clear and honest understanding of the events that led to our daughter’s death,” adds Raeline. “This disclosure led to further apologies and opened up a series of other actions and meetings with the people directly involved in Claire’s care that resulted in improvements in the safety of care at the hospital.”

Raeline reinforces the importance of sharing information as openly and quickly as possible and to involve families in the discussion as to what happened. “With everything we did, we wanted to ensure it would not compromise another analysis.  We set out to find where the system and the processes went astray and to make it better for those who would come behind.  The apology is foundational.  With the  analysis and follow-up we were able to move to the next phase taking Claire’s 16-day episode of care and looking at it as a catalyst for change.”

Raeline and David applaud the Eastern Regional Integrated Health Authority in Newfoundland and Labrador for carrying out a timely and fulsome review of what happened and why, fully sharing the report’s contents, and implementing the recommendations.

Effective management and analysis of patient safety incidents provides an opportunity to make care safer.  The learning gained from a potentially very difficult situation can lead to something positive by reducing the likelihood of recurrence. The Canadian Incident Analysis Framework is a valuable resource that individuals and organizations can use to analyze and learn from patient safety incidents.

Originally developed as a Root Cause Analysis Framework in 2006, the revised Canadian Incident Analysis Framework contains lessons learned from practitioners and researchers, and better reflects the realities and needs of healthcare organizations to analyze and manage patient safety incidents. Key enhancements to the framework include: the patient/family perspective, multiple methods to analyze incidents, placing analysis in the incident management continuum, innovative diagramming, and a new section on developing and managing recommended actions.

The Canadian Incident Analysis Framework and supporting resources can be found by visiting www.patientsafetyinstitute.ca.  The framework can be downloaded for free and printed copies are available for purchase.  Feedback and questions are welcome via email at analysis@cpsi-icsp.ca.  Send comments and questions related to medication safety to analysis@ismp-canada.org