By Bjørn Andersen, Tom Fagerhaug, and Marti Beltz
The impact effort matrix was designed specifically for the purpose of deciding which of many suggested solutions to implement. It provides answers to the question of which solutions seem easiest to achieve with the most effects.
The steps in constructing an impact effort matrix are:
Mr. A. Smith was a comatose patient with respirator dependency undergoing an inpatient admission for the treatment of infection at a long-term acute care hospital (LTACH). During his admission, the patient destabilized and suffered cardiac arrest requiring emergency transportation to the hospital system’s acute care facility.
An ambulance service was dispatched to transport the patient stat. The nursing staff photocopied portions of the chart for transport with the patient. Additional portions of the chart were faxed to the acute care facility after the patient had departed the LTACH.
Once at the emergency room, the patient was treated according to his presenting symptoms and the history included in the photocopied chart pages. It was only when the faxed chart materials were received that a nurse recognized that the transported chart copies were for Mr. B. Smith, another LTACH patient on the same unit, and not for Mr. A. Smith. This precipitated a change in treatment (a “near miss”) prior to giving the patient a medication to which he was highly allergic.
The event was investigated, and several proposed solutions surfaced:
|1||Create a policy for matching patient ID to chart ID at every point in transfer|
|2||Train every employee on patient identification policy|
|3||Bar code patient ID bands and charts; match before transport|
|4||Implant a radio frequency identification number (RFID) tag under the skin of patients and attach to each medical chart for matching at each transfer point|
Excerpted from Bjørn Andersen, Tom Fagerhaug, and Marti Beltz, Root Cause Analysis and Improvement in the Healthcare Sector: A Step-by-Step Guide (Milwaukee, WI: ASQ Quality Press, 2010), pages 19, 146-147.