Use OASIS education to report adverse events
Use OASIS education to report adverse events
Show nurses how to answer OASIS questions
Has your agency been seeing unusual numbers of adverse event reports with the introduction of the Outcome and Assessment Information Set (OASIS)?
If so, the problem may not be the quality of your care. The answer may be as simple as teaching nurses to more carefully answer the OASIS questions to better reflect the patient’s true condition at admission, says Jean Arias, RN, CHCE, administrator at Baptist-South Miami Home Care. "I think across the nation, people are finding that their adverse event reports have picked up some problems in their agencies. And basically, some of those problems are simply the nurses not answering the OASIS questions correctly."
Arias and Mervita Byer, RN, director of professional services for the agency, have been developing educational and auditing tools to help pinpoint nurses’ difficulties with the OASIS questions and resolve them.
They say an agency should be looking carefully at every adverse event — regardless of whether the agency’s numbers exceed average — to determine the cause of the problem.
In fact, Baptist-South, which admits about 3,000 patients a year, is working to pick up potential problems even sooner — by auditing all charts on discharge and looking for adverse events before a report is even generated.
Not only will this help find cases that are improperly labeled as adverse events, but it helps point to real problems that should be promptly addressed.
Unexpected death reports
As an example of how a closer examination of adverse event reports might help an agency, Arias and Byer cite the most extreme of adverse events — an unexpected death.
Often, they say, patients whose deaths are classified as unexpected are those who nurses knew were declining and likely could die sooner than six months after admission. However, because a doctor had not formally given the patient a terminal diagnosis, they were answering the key OASIS question, M0280, by stating that the patient had a life expectancy of greater than six months.
"Because [the patient] hasn’t been labeled terminal,’ the nurses won’t put that they expect death in six months," Arias says. "And in fact, the patient dies. Well it’s no big surprise, however, it is an adverse event."
This did, in fact, happen with a patient at Baptist-South, Arias says, prompting the agency to look at how nurses answer the M0280 question.
Now, nurses are taught to use their own judgment to answer that question, based on the diagnosis and other factors.
For example, Byer says, if a nurse admits a patient with chronic obstructive pulmonary disease (COPD) who is clearly declining, although not formally labeled terminal, she could choose to answer on M0280 that she believes the patient has a life expectancy of less than six months.
"If it’s someone with end-stage COPD who the nurse has seen before, who is progressively going downhill, you know that person can really get into trouble at any point," Byer says. "At that point, I could say, I’m going to give this patient six months or less.
"If I’m wrong, fine, because the patient is still going to live and is going to be OK," Byer says. "But if I see that the patient continues to deteriorate and I don’t do this, then it’s going to come to me as an adverse event because the patient really could go within six months."
Another red flag would be a patient whom the doctor refers to hospice, but who refuses hospice care. "That is telling me that this should really be looked at because the doctor or the social services at the hospital think that hospice is warranted, but the patient is refusing, because of denial or whatever," Byer says.
She would choose to answer M0280 by stating she believes the patient has less than six months to live, "because this was foreseen by somebody else, even if the patient or the family were not really accepting it."
In fact, Healthcare Financing Administration’s (HCFA) own instructions on answering question M0280 call for the interviewer to use past health history, observed health status and other sources as well as the physician’s expectations, to form a judgment regarding life expectancy.
Instructing nurses to make these kinds of judgments required inservicing that went into detail on all of the OASIS questions having to do with adverse events. "We educated nurses as to the standard and what HCFA really meant, what was really meant when OASIS was developed," Arias says. "So now we’re clear, and we feel that the answers the nurses will give will be accurate."
Byer says it can be a challenge to get nurses into the mindset that they can apply their own judgment to the OASIS assessment. "The nurses are becoming more accustomed to taking hold of something like that and making a decision that is only really for the OASIS outcome."
Nurses who seem to have the most problems with OASIS are assigned to an OASIS instructor who deals in small classes of two people for about half a day.
Byer says the instructor has told her he has seen tremendous improvement in those nurses who have gone through the intensive training.
Develop policy for handling adverse events
Baptist-South’s audit program also points to situations in which an adverse event report may be warranted, but isn’t the result of poor care, Arias says.
For example, she says, a patient may be discharged while unable to take medication unassisted, but may have family members or caregivers in the home who administer the medication.
"On admission, we have it documented that the patient’s family or caregiver is administering those medicines," Arias says. "Then on discharge, the family or caregiver is still administering those medicines. Yes, that OASIS question will show that the patient has not improved, however, when the surveyor comes out to review the chart, he or she will see that it’s justified. The patient was in fact, safe on discharge and we did not underutilize in the visits."
Arias estimates that of the 13 adverse events, some agency in the country is having problems with at least one of them. "We just came from a meeting in Washington, and some agencies have problems with almost all of them," she says.
She says agencies trying to get a handle on adverse event reporting should first figure out a consistent process for dealing with the reports as they come up.
In each case, the agency should deal with the chart and with the nurse or therapist involved. Then, if a problem is uncovered, it should be disseminated to the entire staff, since the issue will probably come up again. "If it’s only a documentation error, or an error in the concept of how the nurse should answer the OASIS question, then that’s a simple one to deal with," Arias says.
Another guideline is to use the Joint Commis-sion on Accreditation of Healthcare Organizations’ standard for dealing with sentinel events.
Most importantly, Arias says: Use the adverse events reports as a guide to educate staff and don’t be afraid of them. "Anytime we know the surveyors have information and they’re going to come and survey us, it creates fear," Arias says. "But if you’re working on it and you put a program in place to work on it, and use the Joint Commission criteria toward the adverse events, your program should work out pretty well."
• Jean Arias, RN, CHCE, Administrator, and Mervita Byer, RN, Director of Professional Services, Baptist-South Miami Home Care, 9350 Sunset Drive, Suite 118, Miami, FL 33173. Phone: (305) 596-4343. Fax: (305) 270-9501. [email protected].
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