Developing Safety Programmes in Regional Hospitals

PSC & PIPSQC Paediatric Patient Safety DayBirmingham, May 20th 2013

Dr. John FitzSimonsHSE Ireland

Dr. Santanu MaityRoyal Free Hospital, London

At the end of this session you will be able to….

• Discuss some of the unique features of paediatric patient safety

• Understand the challenges when developing paediatric patient safety in a regional centre

• Plan strategically for paediatric patient safety

• Describe some proven safety solutions and know how to implement them

What is patient safety?

“The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”

Charles Vincent

A Story…

Organisational Accident Model

Harm

Management decisions

& Organisational

processes

Environment factors

Team factors

Staff factors

Task factors

Patient factors

Unsafe acts

Errors

Violations

Organisation & Culture

Contributory factors

Care delivery problems

Defences & Barriers

Latent failures

Active failures

Errors of Omission

“On average, children received 46.5% of the overall indicated care”

Error & Harm

ErrorHarm

Non-preventable

Preventable

Group Discussion 1

What makes paediatric patient safety different?

Patient FactorsUnique Features of Paediatric Care

Difference (4 D’s) Safety implicationDevelopment - Physical

- Psychological

- Emotional

e.g. age weight changes, changes in pharmacokinetics, Increased susceptibility to infection

Communication, consent

Dependence (on adults) Wrong details, various people giving meds etcConsent

Different disease epidemiology

Rare diseases – rare treatments

Demographics Poverty, language barriers

System Factors

System Factors

Adult setting Paediatric setting

Team Interchangeable (e.g. hospital at night)

Specific

Tasks Routine Adapted around patient

Tools & Technology

Standardised. Designed for adults

Patient specific. Adapted from adults

Work environment

Designed for adultsBuilt for medicine past

Often share adult resources, labs, radiology

Organisation Larger Smaller. High profile

NPSA Safety incident reports(Children Vs Adults)

Problem Children AdultsMedication 19% 9%

Treatment/procedure problem

14% 7%

Device problem 6% 3%

Consent issue 7% 4%

Patient accident 13% 41%

Safety Solutions

“We cannot change the human condition, but

we can change the conditions under which humans work”

James Reason

Group Discussion 2

What are the challenges for paediatric patient safety in a regional setting?

Some Challenges for Paediatric Patient Safety in Regional Settings

• Small units, fewer staff• Paediatrics usually left until “we get it right elsewhere” • Many services are shared:

- A&E, OPD, Theatre- Surgery & Anaesthetics (and their trainees)- Diagnostics (Laboratory & radiology)- Allied professionals- Pharmacy

• Most research comes from children’s hospitals

Group Discussion 3

What would a safe paediatric service look like in your hospital?

Harm Free Paediatrics

1. No, or the very least, pain or distress.2. No unnecessary investigations or admissions or

treatments.3. No tissue injury - extravasation, pressure or other.4. No hospital acquired infections.5. No medication or fluids injuries.6. Recognise sepsis or other life threatening events as

early as possible and institute the right treatment.7. Safeguarding with safe care

Dr. John Fitzsimons

Make Space for Improvement

“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.” Winne the PoohA.A. Milne

First Steps

• Will, Ideas, Execution

• Have an aim – SMART

• Have a strategy – driver diagrams

• Have an improvement method - Model for Improvement

SMART Aim

SpecificMeasurableAchievable

RealisticTime bound

Aim – “Improve hand hygiene”

SMART Aim

SpecificMeasurableAchievable

RealisticTime bound

Aim – “Improve hand hygiene for all staff on the children’s ward to over 90% of cleaning opportunities by the end of June 2013”

Primary Drivers(Processes, rules of conduct, structure)

Secondary Drivers(Components & activities leading to 1º drivers)Driver Diagram

Aim

DressingPlates

Crispy Skin

Moist meat

flavoursome

Perfect Stuffing

Great Gravy

Good Presentation

Primary Drivers(Processes, rules of conduct, structure)

Organic chicken Herbs

Secondary Drivers(Components & activities leading to 1º drivers)

Basting SeasoningHeat

Driver Diagram

StockWineflavourings

Components – Chestnuts, bread Volume

BriningSlow & low cooking

The Perfect Roast Chicken

Safety a the top of the agendaSafety cultureClear information on safety and harmWalkabouts

Improve safety on children’s wards

Communication

Medication harm

Early detection & rescue of sick child

Parental involvement

Measure harm & learn from serious events

Heathcare assoc infections

Management & leadership

Primary Drivers(Processes, rules of conduct, structure)

Situation awareness (PEWS)Safety briefingsImprove rescue – Simulation, debriefing, RRT

Secondary Drivers(Components & activities leading to 1º drivers)

Handover (SBAR & Critical language)Photo boardsProformas for admission

Driver Diagram

Become a learning organisationInstitute GTTSUI team Rapid reviewsDebriefingsFormal response to all/selected incidence forms

TransparencyOn safety committee/teamAbility to effect change

Prescribing criteriaStandardised medication guidelines

Improve hand hygieneSurgical site infections

The Improvement Guide, API

Aim

Measures

Changes

Execution

The PDSA Cycle for Learning and ImprovementWhat change can we make that will result in an improvement ?

Act• What changes are to be made?

• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)• Plan for data collection

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

Repeated Use of the Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A PS D

APS

D

A PS D

D SP A

DATA

Group Discussion 4

How might you achieve Harm Free Paediatrics where you work?

A few ideas we’ve tried…

• Situation awareness

• Communication

• Bundles

• Bring consultants to the front 24/7

PEWS Background

• CEMACH report “Why Children Die” found preventable factors in 26% of reviewed cases

• Centres with PICU and rapid response teams have used PEWS to trigger the team.

• No accepted model

“Brighton” PEWS

PEWS: 24 PDSA Cycles in 9 Months

K

RFH PEWS

• Scores on 7 parameters

• Set actions according to score0-1 Continue observations2 Nurse in charge review3 Above plus SHO review4 Above plus inform registrar5-7 Registrar review +/- Crash call

SBAR

SituationBackgroundAssessment

Recommendations

SBAR

• Situation– One sentence description of problem

• Background– Details that give information

• Assessment– What you think about the problem

• Recommendation– What you think needs to be done

SBAR Modifications

• iSBAR – identification of yourself, your location and your patient.

• SBAR with a Readback – After handover give a readback of highlights

SBAR Notes• 11 Essential components of a

hospital note1. Patient ID2. Date3. Time4. Context5. Situation6. Background7. Assessment8. Recommendation9. Signature10. Print Name11. Medical Council Number

Improvement Process

• Education• Prompts• Measurement and feedback• Twice a week, up to 10 charts if

available- Individual (out of 11)- Bundle (11 out of 11)

• Changes- More education- Individual feedback- Consultant ownership

Dr. John Fitzsimons - Presentation to National Clinical Leads

Use data to drive ChangeSBAR Notes

0%10%20%30%40%50%60%70%80%90%

100%

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk8/Dr. A

Wk 9/Dr B

Wk 10/Dr C

Wk 11 /Dr D

Wk 12/Dr E

20-Apr 27-Apr 05-May 09-May 18-May 25-May 30-May 03-Jun 07-Jun 17-Jun 22-Jun 29-Jun

Weeks

% C

ompl

ianc

e

Items

Bundle

Re-education and individual feedback

Named consultantEducation and visual reminders

25/10/2012

“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”

Sir Liam Donaldson

Questions welcome