Quality Assurance/Quality Improvement
The clinical staff must be vigilant to ensure high-quality patient care that includes identification of adverse events and occurrences that may be preventable. Untoward events may occur as a result of practitioner or staff errors, unfamiliarity with protocol requirements, or inadequate policies related to patient care. The Clinical Center has established an electronic Occurrence Reporting System (ORS) for use by staff to report, review, and respond to patient-related occurrences. The purpose of the ORS is to inform senior leadership of these events and offer the opportunity for further study to determine which of these events might be preventable. The system also affords CC leadership and clinical staff the opportunity to see whether interventions designed to reduce risks for untoward occurrences are effective.
To review the occurrences and complications of procedures that caused—or had the potential to cause—patient harm, the institutes and centers should conduct Quality Assurance/Performance Improvement Rounds on a regular basis. These rounds also provide an appropriate opportunity to discuss especially serious outcomes of protocol participation—even when unassociated with an occurrence or procedural complication.
These conferences, which should be attended by all levels of patient-care staff, will regularly include the unit nurse manager and other representatives from the nursing staff. When appropriate, other key staff (e.g., from the Pharmacy or Social Work Department) may be included.
The goals of these meetings are to identify policies or practices that may have contributed to the occurrence and to formulate measures to prevent recurrence of these events. Occurrences that are particularly serious or complex should be brought to the attention of appropriate Clinical Center leadership. The Clinical Center leadership will (1) initiate a root-cause analysis for determining the cause(s) of the event and (2) formulate preventive actions. The Medical Executive Committee will be informed about the results of root-cause analyses that have broader implications for patient care and will advise the CC Director about the implementation of strategies designed to address identified deficiencies in patient-care processes.
The leadership of the institutes and centers should encourage their staffs to use the Occurrence Reporting System because of the opportunity it provides to improve the quality of patient care at the Clinical Center.
Confidential documentation of these rounds should be maintained, and changes in policy or practice disseminated to all patient-care staff.
The institute and center leadership should keep records of rocedural complications and actions taken to prevent future occurrences, where appropriate. These actions may include supervision, additional training (here or elsewhere), or termination of privileges to perform specific procedures.