The goal of any retrospective review is to promote learning for the purpose of improving the quality of care for patients. Occasionally, specific adverse events and near misses require an immediate system response and trigger a Rapid Response Review.
If required, a rapidly mobilized review process is initiated. Rapid Response Reviews are similar to other types of retrospective patient focused reviews in that they include information gathering, analysis, and developing recommendations to mitigate or eliminate the risk of recurrence. The review findings and recommendations are then shared for learning and implementation.
However, these reviews are distinct in that the term ‘rapid response’ refers to the pace at which the review is conducted and that it may be characterized by a pause in clinical activity. This pause in activity allows staff directly involved in the event to participate in the review process and identify ways to mitigate risk.
Seven types of adverse events and near misses may trigger this review process:
1. Surgical Events (e.g., surgery performed on the wrong body part, retention on a foreign object in a patient after surgery or other procedure)
2. Product or Device Events (e.g., patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by VIHA)
3. Patient Protection Events (e.g., an infant discharged to the wrong person, patient suicide or attempted suicide resulting in serious disability while being cared for by VIHA)
4. Transition and Transport Events (e.g., patient death or serious disability incurred as a result of transport arranged or provided by VIHA)
5. Care Management Events (e.g., patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or other tissues)
6. Environmental Events (e.g., patient death or serious disability associated with non-therapeutic electric shock while being cared for by VIHA)
7. Criminal Events (e.g., abduction of a patient of any age)
Rapid Response Reviews may be managed locally, with or without the support of Quality and Patient Safety (QPS). In the case of a Complex Review, QPS may provide support for the review process.
Once a Rapid Response Review is initiated the process is guided by the principles of responsiveness and participation. Overarching principles of the Combined Quality System – respect, shared accountability, and shared information – also apply.