Frequently Asked Questions

Frequently Asked Questions

General

1. There is concern about implementing the entire system at once. Is there a step-wise way to implement so that we are no so overwhelmed?

An organization transitioning into near miss reporting event reporting can experience as much as a ten fold increase in the amount of information reported into the system. The increase will not be as marked if you are already collecting near misses. To avoid getting more reports than can be processed while learning a new methodology, we recommend that the QA SysOps learn how to do causal trees, code, and analyze the data before training the staff.

Event Types

1. What is the difference between an unplanned recovery and a planned recovery?

A planned recovery occurs when an event is detected because of a mechanism already built into your process. For instance, a computer program that compares current blood type with a historical blood type is a planned recovery as is an administrative review step written into a SOP. These two types of recoveries have very different levels of reliability, but are explicit steps in a process.
An unplanned recovery means that an observant person just happened to notice that something was not as it should be.

Causal Trees

1. I can identify a consequent event, but then have a difficult time building a tree below it following the "ask why five times" format.

The wording of the consequent event is key to the flow of the causal tree. If the antecedent events that come to mind do not answer the "why" question, then try rewording the consequent event.

A common problem is to use an antecedent event as the consequent event, which narrows the scope of the investigation.

2. Why is the structure of the MERS-TM tree is different from other causal trees I have seen in the past?

In order to facilitate data analysis and coding, it was necessary to standardize how the major blocks of information are laid out on paper. This way, all the major antecedent events are on the same level in the causal tree, in chronological order, from left to right.

3. How long does it take to build a causal tree?

There is a learning curve and the more causal trees are built, the easier the process becomes. Once fully trained, it should take approximately 20 minutes to build the average causal tree. This does not include investigation time.

Event Coding

1. I coded many of my consequent events in the Product Administration (UT) category since the events were discovered after the products were given to the patients. However, when analyzing these data, it erroneously appeared that many unsafe products were leaving the transfusion service and getting to the patient. Actually, the safety, purity, potency, efficacy were not affected. Should these events be coded in a different manner?

If the event and its associated products did not have the potential to harm the patient, then the event should not be coded to reflect where the product was at discovery. Instead, focus on the process that was occurring when the event was detected and code that process as the consequent event. See Event Coding for more information.

For example, if when you turn the heat block on in the morning, it never gets up to the required temperature, no products were involved, so you would code this as an instrument problem in sample testing, captured by a sample testing review process.

2. What if the event I have does not match any of the sub-process codes?

The sub-process codes often will not match the event exactly. The most important element of the coding to do correctly is the process code. Below that level, events are differentiated based on the sub-process codes and the narrative blocks. Therefore, either use the sub-process code that comes closest, or use "other" code. If the "other" category is used too frequently, the MERS-TM staff are open to suggestions for improvements either by modifications of existing verbiage or additions of new codes.

Cause Coding

1. When coding external causes, how do I decide between OEX and HEX?

External causes are sometimes difficult to code because the circumstances are outside the scope of your event management system. External decisions about budget issues that have adversely affected your department would be coded as OEX. A situation in which a sample has been mislabeled by someone outside the transfusion service would be coded as an HEX. However, if there are several HEX codes related to sample mislabeling in one area, there may be an underlying organizational issue. Future mislabeling events should be coded as an OEX