Microsoft word - rm_synopsis_1_2_3_2010_201

PERIODS (1-2-3) FROM APRIL 1 TO JUNE 19, 2010
This progress report summarizes the activities and achievements for the period of April 1st, 2010 to June 19th, 2010 pertaining to risk management and the use of restraint and I. RISK MANAGEMENT
In total, 406 incidents and accidents1 were reported between April 1st, 2010 and June 19th , 2010; 134 incidents and 272 accidents were reported. Incident/Accident Reports
Based on the number of declarations
1 Incidents are situations that do not have consequences on the state of health or welfare of a user, but their outcome is unusual and could have had consequences under different circumstances. Accidents are situations where the user is directly affected by the event; this situation has or could have consequences for the state of health or welfare of the Incident/Accident Reports
Based on the Severity scale
rating of incidents/accidents
Sentinel H (intervention to sustain life) Accident I (accident resulting in death) It should be highlighted that 89% of the incident/accident reports, correspond to levels A, B, C, D and E1 in severity scale. The incident/accident reports with a level of severity of A, B and C are referring to events without consequences, D level reports are events requiring surveillance in case of a consequence, and level E1 reports are events with minor consequences that did no require specialized treatment. Furthermore, it is important to specify that from the 40 accidents with a level of severity E2 (10%), 13 accidents (3%) are events that had significant consequences for the user (falls, victim of aggression, theft with legal consequences, accidents with injuries etc). The other events were without major consequence to the user, however they required the intervention of the police (disappearance/leaving without authorization), or medical treatment (health related problems and infections). Regarding the 4 hospitalizations corresponding to a level of severity F (1%), they were strictly health problems (for example: infection, heart problem, pneumonia, etc.). Concerning the sentinel accidents, the DSP was informed of two cases and the necessary measures were put in place. For the first case, the client suffered burns while playing with matches and the second, the user ingested medications while visiting his Incident/Accident Reports
By type of event
Victim of aggressions (staff member victim) Medication
As indicated in the above table, aggressions represent more than half of incidents/accidents declared (55%). Of this number, it should be noted that out of the 226 aggressions reported, in 31 cases the user was the victim and in 81 cases the victim was a staff member. The second most important type of incidents/accidents reported is By type of “Miscellaneous” event
%(of the 406
Other types of accidents without injuries Theft of material (User is the perpetrator) Total 118
Although 31 % of incidents/accidents fall under the "miscellaneous" category, it should be noted that they include a large number of different types of events that are non- significant in terms of percentage (from 1 % to 5 % of reported events). However, it is important to clarify that each of these situations has been analyzed by the service where it occurred and appropriate measures have been implemented or recommended in order to prevent their reoccurrence. Furthermore in order to have a better classification of the events that fall under “miscellaneous”, 2 new sub-categories were created: Injury-cause identified and Epilepsy/seizure (unusual seizure). Incident/Accident Reports
By type of program
Residential Integration
Work and Community Integration
Individual, Family and Community
Support Program
When looking at the data by type of program, 65% of the events have occurred in residential services while 33% of incidents and accidents have occurred in Work or Community Integration services. It is also important to mention that in the residential resources 162 of the 266 incidents/accidents were reports of aggression (61%). In the Work and Community Integration services, 61 of the 133 reports were also reports of Only 2% of the events have been observed within the Support Program (to the person, the family and the community). This low percentage can be due to the fact that clients participating in this program live in their natural family and that, in this context, not all events are reported to the establishment.
Internal Investigations
In collaboration with the Department of Client services, the Department of Professional Services completed two internal investigations during the period of April 1st and June 19th 2010. The first investigation pertained to an allegation of physical abuse involving a shadow at school and the other, to a breach of standards of care and of the caregiver’s contract; for this second investigation the caregiver’s contract was terminated.
Additional recommendations made following the conclusion of the investigations
included the following:

ƒ Evaluation of the quality of services of the resource in order to provide a spedific ƒ Evaluation of the clinical and administrative management process in order to ensure leardership with respect to follow ups that must be made and the decisions that must be taken according to the situations. ƒ Ensure the verification of criminal records in the RNI ( contractual agent and the ƒ Request the collaboration of the DSP with respect to the validation process if a resource makes specific modifications to the initial service contract. Integrated Risk Management Committee
During the period of April 1st to June 19th, 2010, the Risk Management Committee had one meeting on June 15th 2010. The main themes discussed during were the following: (1) accreditation requirements (2) medications errors and action plan targeting prevention strategies, (3) fall prevention strategies and the involvement of the division of research and education (in DSP), (4) follow-up system for the incident/accident reports level E2 (and higher) and ( 5) terms for the disclosure of accidents involving a user. Action taken by the Integrated Risk Management Committee
1) Reorganisation of the Risk Management Committee
In order to have a better circulation of the information, a quicker response when putting in place action plans following accidents and to ensure that all directions play a role in risk reduction and quality improvement, the committee now includes representatives from different departments, DSAF, DSEF and DSA. With this new structure, the committee will now be called Integrated Risk Management Committee. An information capsule is being elaborated in order specify the roles and the 2) Follow-up of incident/accident reports with a gravity scale E2 (and higher)
A new system has been put in place in order to do more detailed follow ups of incident/accident reports with significant consequences to the user. At each Integrated Risk Management meeting the cases are reviewed, analyzed, systemic measures are identified and the necessary follow ups are done in order to ensure that all adequate action plans are put in place. 3) Involvement of the division of research and education (in DSP) for the creation
of sub-committees for the identified high priorities by the Integrated Risk
Management Committee
The involvement of the research department was requested in order to: (1) better analyse the data provided by the incident/accident reports, (2) explore new avenues of research and specific variables (3) identify hypothesis, the main problematic and causes of incidents and accidents in order to inform the existing sub-committees for medication errors, fall prevention and aggressive behaviours. 4) Medication Management and Prevention Control of infections ( Accreditation)
ƒ The procedures for the administration of medication have been reviewed. ƒ A new system for the Bubble Pack previously known as the Blister Pack will be progressively put in place after the necessary training sessions are given ( ƒ In the Fall, training sessions for the prevention of infections will be provided to all employees, caregivers the users and their families. 5) Safety and Security
ƒ The standards of care are being reviewed and will integrate the emergency ƒ A questionnaire was distributed in order to identify if the resources comply with 6) Recommendations regarding Coumadin (anticoagulant) and the application of
physical and mechanical restraints:
ƒ There is a high risk of injury (internal haemorrhage) if a control measure is applied to a user that is taken a anticoagulant therefore, follow-ups were made with the users with control measure contracts to determine if they are taking Coumadin and specific instructions have been established ƒ Additional follow-ups with all users taking Coumadin or any other anticoagulant are also being done. A letter was sent to the DSC to identify the users who are taking anticoagulants and the following steps have to be taken in order to have an accurate list of the users that are taking this kind of medication ƒ Involve ARH to obtain the necessary information 7) Users at risk of choking
ƒ A list of the users who tend to steal food is underway (these users are at-risk); ƒ A list of the users who eat pureed or soft food has been provided by the occupational therapist and the nutritionist ƒ A re-evaluation of the environment (kitchen) will be done to ensure that the environment is safe (block unless supervised access to the kitchen to ensure that 8) Fall Prevention Program
ƒ The Screening Grid/Chart has been finalized and pilot sites have been identified. ƒ The grid is currently being used in those pilot sites ƒ Specific instructions for the use of the grid will be finalized in September 2010 ƒ In the fall, training session will be given to employees, caregivers and the users Follow-up on Incident/Accident reports
During the period of April 1st to June 19th 2010, the Department of Professional Services (DSP) provided support and follow-up on all incidents/accidents. Furthermore, in some particular cases, specific interventions were made by the DSP with the directors of client services in order to reinforce the safe provision of services and to reduce the occurrence of incidents/accidents that could have led to a sentinel event. RESTRAINT AND ISOLATION MEASURES
Summary of Restraint and Isolation Measure Contracts
Number of users with a
restraint/isolation measure
Suspension of a
New requests for
restraint/isolation restraint/isolation
During the period of April 1st to June 19th 2010, restraint and isolation measure contracts were authorized for a total of 25 users. All contracts are required to be reviewed every 2009-2010 On March 31st 2009, twenty-four (24) users had a control measure contract in effect.
2 Control measure: Measure that involves controlling a person displaying aggressive behaviour by
restricting that person’s movements and displacements (isolation, physical and mechanical restraints)
3 Support measure: Measure that involves restricting a person’s movements and displacements in order to
prevent any risk of accident or impairment to health (mechanical restraints)
4 Isolated care measure: Measure that involves immobilizing a part of a person’s body during a particular
treatment (physical and mechanical restraints)



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(mas os controladores precisam mais do que isso!) Por Eduardo SILVERIO de Oliveira - Cap Esp CTA O autor é Chefe da Subdivisão de Infra-estrutura do ICEA e mestrando em Educação na Universidade de São Paulo (USP), na linha de pesquisa Educação e Linguagem. Toda vez que se pensa no ensino do inglês mais cem mil membros das forças armadas. no SISCEAB, logo vem a necessidade do uso d

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