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Microsoft word - rm_synopsis_1_2_3_2010_201
ACTIVITY REPORT - INTEGRATED RISK MANAGEMENT 2010-2011,
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.
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
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
By type of event
Victim of aggressions (staff member victim)
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)
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).
By type of program
Work and Community Integration
Individual, Family and Community
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.
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:
Evaluation of the quality of services of the resource in order to provide a spedific
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.
Ensure the verification of criminal records in the RNI ( contractual agent and the
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
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)
The procedures for the administration of medication have been reviewed.
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 (
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
The standards of care are being reviewed and will integrate the emergency
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:
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
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
Involve ARH to obtain the necessary information
7) Users at risk of choking
A list of the users who tend to steal food is underway (these users are at-risk);
A list of the users who eat pureed or soft food has been provided by the
occupational therapist and the nutritionist
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
The Screening Grid/Chart has been finalized and pilot sites have been identified.
The grid is currently being used in those pilot sites
Specific instructions for the use of the grid will be finalized in September 2010
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
Suspension of a
New requests for
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