The analysis of adverse events associated with care (EIAS) and ESSMS

Source: 📒 The analysis of adverse events associated with care (EIAS) and ESSMS

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1. Analytical summary – ESSMS version

1.1. Context and issues for ESSMS

The guide starts from the observation that theadverse events associated with care and supportconcern not only hospitals, but alsosocial and medico-social establishments, with specific forms: falls, abuse, medication errors, escapes, violence between residents, infectious risks.

It articulates thescientific definitions (WHO–HAS)andregulatorydefinitions of EIAS, EPR and EIGS, reminding that social and medico-social establishments are concerned by thedeclarations of EIGSwhen there is a health-related care or support act.

The document targets "all care and support professionals", which includes themulti-professional teams of social and medico-social establishments: caregivers, educational staff, medico-psychological staff, paramedics, management, directors.

For social and medico-social establishments, it directly meets the requirements of theHAS quality assessment framework: objectives 3.13 (adverse events) and 3.14 (risk management), which requireto demonstrate a structured system for collection, analysis and communication..

The stakes are:to secure the pathways of vulnerable individuals, to support teams exposed to serious events, to structure the relationship with families in these sensitive situations andto demonstrate risk management to external evaluators..

1.2. Operational contributions for social and medico-social establishments

The guide proposes afour-step approach.applicable in care homes, MAS/FAM, group homes, home services:1) reconstruct the chronology, 2) investigate theimmediate and underlying causes, 3) analyse thesafety barriers, 4) define theaction plan and follow-up.

It providesdirectly usable toolsin an ESSMS: EIAS/EPR/EIGS qualification grid, updated ALARM grid, cause tree, 5 whys, Tempos, action tracking table, self-assessment of the quality of the analysis.

The guide emphasises themulti-professional participation(including educators, AMP/AES, psychologists, managers and coordinating doctors) and thejust culture, essential for encouraging open communication in teams sometimes marked by fear of blame.

Therole of the resident and/or their familyis considered through aninformation sheetand ainterview grid, allowing for the collection of their narrative and expectations without putting them in difficulty, which is crucial in situations of dependency, disability or cognitive disorders.

The sheets on "feedback", "safety culture", "human error", "legal aspects" assist management and quality referents in ESSMS toformalise a procedure for managing undesirable eventsmeeting criteria 3.13.1 to 3.13.4.

2. Key points of the document – focus on ESSMS

1. A common EIAS/EPR/EIGS framework adapted for ESSMS

   The guide provides clear definitions ofEIAS, EPR and EIGSincluding situations in ESSMS: serious falls in care homes, violence or abuse, absconding with consequences, medication errors, care-related infections, suicide or attempts.

   Useful for ESSMS to structure theirevent typologyand harmonise reporting and prioritisation criteria. (p. 6–8, 33–34)

2. An analysis approach directly transposable to ESSMS

   The four steps (chronology – causes – barriers – action plan) allow for the analysis of afall in the bathroom, a conflict with a family, a treatment error or an incident during a transfer to the hospital.

   The proposed grids can be integrated as they are into anESSMS procedure for managing adverse eventsto meet criterion 3.13.1. (p. 10–27, 52–53)

3. An ALARM grid usable in medico-social teams

   The ALARM grid 2024 covers contributory factors that are very present in ESSMS:resident vulnerability, caregiver/educational coordination, day-night continuity, staffing, premises, information systems, institutional culture.

   It helps to avoid analyses focused on a single person and to objectify organisational causes (planning, training, protocols, management). (p. 14–16, 35–39, 66–69)

4. A place designed for residents, users and families

   The guide offers apatient interview gridand aninformation sheet, transposable toresidents, users and guardiansin ESSMS, with adaptation to cognitive disorders and vulnerability.

   This allows for a response to both thesafety cultureand the spirit of the ESSMS framework regarding theparticipation of supported individualsand the CVS. (p. 11–12, 21, 54–59)

5. A foundation to structure the response to criterion 3.13 of the ESSMS framework

   By combining sheets, tools and examples, the guide provides a basis to show that the ESSMSorganises the collection, team analysis, communication and trainingaround adverse events, as requested in criteria 3.13.1 to 3.13.4.

   Usable as anexplicit referencein the internal procedure and external evaluation supports. (p. 28–31, 61–63, 70–72)

3. Action points for local actors – ESSMS

1. Build an ESSMS procedure for managing adverse events based on the guide

   Draft or update aninternal proceduredescribing: collection of events, prioritisation, deadlines, analysis (4 steps), validation of action plans, communication and archiving, explicitly citing the HAS-FORAP guide as a reference.

   Integrate thechronology, causes (ALARM) and action plan tablesas annexes to this procedure. (p. 10–27, 52–53)

2. Adapt the grids to typical situations of the ESSMS

   Start from the tools in the guide (EIAS qualification, ALARM, 5 whys, Tempos) to create 2–3simplified grids :

   • falls/fall risk,

   • treatment/preparation errors,

   • situations of abuse/violence/suicide/runaway.

     Objective: oneA4 formatfor each type, usable by managers and referents during analyses. (p. 33–39, 45–51)

3. Organise collective multi-professional and multi-service analyses

   Establish, at least quarterly, aCREX ESSMSor analysis meetings bringing together management, supervision, nurses/social workers, educators, psychologist, coordinating doctor, quality referent, with possible participation of a representative from the CVS for certain themes.

   Systematically use a method (ALARM, Tempos) toavoid informal debateswithout operational outcomes. (p. 13–16, 28–30)

4. Integrate the voice of residents, users and families into priority analyses

   For the most serious or sensitive EIAS (violence, abuse, suicide, runaway), propose avoluntary interviewwith the accompanied person and/or the family, relying on thepatient interview frameworkadapted to the ESSMS context.

   Prepare teams for this approach so that it issecure, non-blamingand compatible with the vulnerability of the populations. (p. 11–12, 54–59)

5. Make criterion 3.13 a major focus of the establishment or service project

   Integrate into theestablishment or service projectan explicit section on themanagement of adverse events, relying on this guide to describe: reporting system, analysis methods, monitoring indicators, regular training for professionals.

   Use theself-assessment grid(tool no. 7) to track the maturity of the approach and prepare for the next HAS ESSMS evaluations. (p. 52–53)

4. Additional references 

🔍➕ For more information, see the articles referenced by "Pratiques en Santé" on the topic of ESSMS ➡️🔗https://pratiquesensante.odoo.com/medico-social-social-essms

5. Cross-analysis — Values of Pratiques en Santé (ESSMS version)

• Literacy: Tool designed forESSMS professionals; no simplified version for residents, but possibility to adapt diagrams and grids for teams with little training in risk management.

• Empowerment: The individuals supported can beconsulted through an experience narrative, but the guide does not formalise a comprehensive empowerment approach (co-construction of action plans, limited role of the CVS).

• Participation: Encourages the analysis of events in amulti-professional teamand the consideration of the patient/resident's perspective; the structured participation of the CVS or user representatives is implicit but not detailed.

• Community health: The collective dimension is situated at the level ofthe ESSMS organisation(safety culture, shared feedback) more than in a broad territorial or community approach.

• Ethics: The consideration ofvulnerabilities(disability, dependence, abuse, sexual violence, detention situation) and the refusal to blame professionals structure an ethical approach to event management.

• Human rights: The implicit reference tothe rights of individuals(information, respect, non-abuse, consideration of psychological consequences) is strong, even if the vocabulary "human rights" is not central.

• Intersectorality: The guide covershealth, medico-social, city, but does not detail the connections between ARS, departments, justice, associations; to be completed locally, particularly on violence, abuse, external reporting.

• Partnership: Encourages partnerships with SRAfor methodological support, and allows for collaboration with user representatives/CVS, without a formalised model of shared governance. pour l’appui méthodologique, et laisse la place à la collaboration avec les représentants des usagers/CVS, sans modèle formalisé de gouvernance partagée.

• Fight against discrimination: Mentions thecontexts of vulnerability(precariousness, disability, detention, sexual violence) and emphasises the non-judgement of professionals, but does not explicitly address racism, sexism or other systemic discrimination.

6. Assessment of the reliability of the resource – view ESSMS

• Scientific: Production HAS-FORAP, based on reference studies (ENEIS, ESPRIT, international literature) and updated in 2026; strong reliability, including for the medico-social field where the literature is more limited.

• Operational in ESSMS :

  • Compatible and consistent with theESSMS framework(objective 3.13) and the expectations of external evaluators.

  • Tools adaptable without major modifications to the realities of ESSMS (multidisciplinarity, multi-sites, significant cultural stakes).

  • Need for awork of appropriation(training, simplification of certain materials) for teams not used to risk analysis.

7. MCQ – 5 questions (ESSMS version)

Part 1 — Questions

Question 1 (p. 6–8)

In anursing home, a fall of a resident during bathing, with a fractured neck of femur, is an example of:

a) A social undesirable event only

b) A healthcare-associated undesirable event (EIAS)

c) An event unrelated to the organisation of the ESSMS

d) An event that can never be avoided

Question 2 (p. 10–12)

To analyse arunawayof a resident in a care home, the first step according to the guide is:

a) To immediately seek who "committed the fault"

b) To reconstruct the complete, factual and pseudonymised chronology of the event

c) To summon the family to decide on sanctions

d) To directly develop a new exit protocol

Question 3 (p. 14–16, 35–39)

The ALARM gridapplied to a treatment error in MAS/FAM primarily serves to: appliquée à une erreur de traitement en MAS/FAM sert principalement à :

a) Identify only the individual error of the AMP or IDE

b) Explore contributory factors such as workload, handovers, and the work environment

c) Classify incidents by service without detailed analysis

d) Decide on the amount of disciplinary sanctions

Question 4 (pp. 18–24)

In a home care service, arecovery barrierafter forgetting a prescribed medication dose can be:

a) The presence of an active CVS

b) The existence of an annual debriefing procedure

c) A quick call to the treating physician to adapt the course of action

d) The general increase in staff without case analysis

Question 5 (pp. 25–27, 28–30)

To meet thecriterion 3.13.3of the ESSMS reference framework, the guide recommends that:

a) The analysis of events is carried out only by management

b) Professionals analyse adverse events as a team using a structured method and implement corrective actions

c) Events are managed on a case-by-case basis, without formalised procedure

d) Analyses are reserved for EIGS and not for other EIAS

Order of correct answers:b / b / b / c / b

Part 2 — Commented correction

Question 1

✅ Correct answer:b) Adverse event associated with care (EIAS).

📝 Explanation: A fall during washing, with injury, is aadverse, unexpected event that occurred in the context of a support or care actin the ESSMS, therefore an EIAS in the scientific sense of HAS. — Source: p. 6–8.

Question 2

✅ Correct answer:b) To reconstruct the complete, factual and pseudonymised chronology of the event.

📝 Explanation: The first step is todescribe the facts in order, without interpretation, specifying who does what, when and how, while respecting the pseudonymisation of individuals. — Source: p. 10–12.

Question 3

✅ Correct answer:b) To explore contributory factors such as workload, handovers and the work environment.

📝 Explanation: ALARM aims for asystemic approach; it encourages analysis of the role of the organisation, the team, the tasks, the patient/resident, beyond just the "individual error". — Source: p. 14–16, 35–39, 66–69.

Question 4

✅ Correct answer:c) The prompt call to the attending physician to adapt the course of action.

📝 Explanation: A recovery barrier occursafter the eventto limit its consequences; contacting the prescriber to adapt the course of action is a concrete example. — Source: p. 18–21.

Question 5

✅ Correct answer:b) Professionals analyse adverse events as a team using a structured method and implement corrective actions.

📝 Explanation: Criterion 3.13.3 expects thatprofessionals report and analyse in teamsadverse events and implementcorrective actions, which the EIAS guide helps to equip. — Source: p. 25–27, 28–30.

8. FAQ – special ESSMS

1. What types of events from an ESSMS are covered by this guide? (p. 6–8, 33–34)

   Falls, treatment errors, absconding, violence or abuse, suicides or attempts, restraint incidents, monitoring errors, delays in accessing care: all these events can be analysed asEIASif they are related to care or support actions.

2. How does this guide help to meet criterion 3.13 of the ESSMS framework? (p. 10–27, 52–53)

   It provides astructured analysis method(chronology, causes, barriers, action plan) and reusable grids to demonstrate that the ESSMScollects, analyses in teams and addressesadverse events in accordance with criteria 3.13.1 to 3.13.4.

3. Who should participate in analyses in ESSMS? (p. 13–16, 28–30)

   The analysis must bemulti-professional: management/supervision, nurse/nursing assistant, care assistants, educators, psychologist, coordinating doctor (if present), quality referent; participation is byinvitation, in a climate of just culture.

4. Can ALARM and the 5 whys be used with teams that are not experts in risk management? (p. 14–16, 45–49)

   Yes, provided that thematerials are simplified, to be supported at the beginning (SRA, training organisations) and to form acore group of referentscapable of facilitating analyses with concrete examples (falls, treatment errors, etc.).

5. What role should residents, users, and families have in the analysis of an EIAS? (p. 11–12, 54–59)

   The guide recommends acollection of voluntary testimoniesusing an adapted interview grid, without imposing participation, while ensuring information, respect, and non-blame of individuals.

6. What to do when the event involves sensitive subjects (violence, suicides, abuse)? (p. 7–8, 70–72)

   The guide reminds of theseriousness of psychological consequences, recommends anappropriate announcement, the protection of individuals and respect for legal obligations (external reporting), as well as theestablishment of support for the professionalsinvolved.

7. Should the analysis report be included in the file of the supported person? (p. 70–72)

   No, theanalysis reportis aninternal management document, pseudonymised, which is not intended to be integrated into the person's file; this aspect is detailed in the 'Legal Aspects' section of the guide.

9. FALC – Summary + key points for ESSMS

FALC Summary – ESSMS

Title: When a serious event occurs in a care home or a shelter

• In an ESSMS, sometimes,an event harms a person.

• Example:fall, medication error, violence, running away.

• This guide explainshow to understand these events.

• It is aimed atprofessionals in the ESSMS.

• The aim is tobetter protect the individuals supported.

• And also tohelp the teamsafter a difficult event.

Title: The four main steps in the ESSMS

• 1:Tell what happened, in chronological order.

• We write simplefacts, without blaming individuals.

• 2: Look forhowthe event occurred.

• We look for theimmediate causesand theunderlying causes.

• 3: See what could haveprevented or limitedthe event.

• 4: Decidewhat to changein the ESSMS going forward.

Title: The individuals supported have a say

• We can offer the person or the family toshare their story.

• This testimony isvoluntary.

• It must be donewith respect and without pressure.

• The objective is tobetter understandin order toact better.

Key points FALC – ESSMS

• The guide helps the ESSMS todeclare and analysethe events.

• He provides asimple methodin four steps.

• He offerstools: tables, questions, concrete examples.

• He thinks ofprofessionalsandthe people supported.

• He helps the ESSMS tomeet the criteria of the HAS

#ESSMS #EHPAD #RiskManagement #PatientSafety #ESSMSEvaluation #QualityOfCare #HealthLiteracy #healthpractices