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Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland.

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Presentation on theme: "Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland."— Presentation transcript:

1 Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland Dr. Santanu Maity Royal Free Hospital, London

2 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

3 What is patient safety? “The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare” Charles Vincent

4 A Story…

5

6 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

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

8 Error & Harm Error Harm Non-preventable Preventable

9 Group Discussion 1 What makes paediatric patient safety different?

10 Patient Factors Unique Features of Paediatric Care Difference (4 D’s)Safety implication Development - 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 etc Consent Different disease epidemiology Rare diseases – rare treatments DemographicsPoverty, language barriers

11 System Factors Adult settingPaediatric setting TeamInterchangeable (e.g. hospital at night) Specific TasksRoutineAdapted around patient Tools & Technology Standardised. Designed for adults Patient specific. Adapted from adults Work environment Designed for adults Built for medicine past Often share adult resources, labs, radiology OrganisationLargerSmaller. High profile

12 NPSA Safety incident reports (Children Vs Adults) ProblemChildrenAdults Medication19%9% Treatment/procedure problem 14%7% Device problem6%3% Consent issue7%4% Patient accident13%41%

13 Safety Solutions “We cannot change the human condition, but we can change the conditions under which humans work” James Reason “We cannot change the human condition, but we can change the conditions under which humans work” James Reason

14 Group Discussion 2 What are the challenges for paediatric patient safety in a regional setting?

15 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

16 Group Discussion 3 What would a safe paediatric service look like in your hospital?

17 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

18 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 Pooh A.A. Milne Dr. John Fitzsimons

19 First Steps Will, Ideas, Execution Have an aim – SMART Have a strategy – driver diagrams Have an improvement method - Model for Improvement

20 SMART Aim Specific Measurable Achievable Realistic Time bound Aim – “Improve hand hygiene”

21 SMART Aim Specific Measurable Achievable Realistic Time 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”

22 Primary Drivers (Processes, rules of conduct, structure) Secondary Drivers (Components & activities leading to 1º drivers) Driver Diagram Aim

23 Dressing Plates 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 Seasoning Heat Driver Diagram Stock Wine flavourings Components – Chestnuts, bread Volume Brining Slow & low cooking The Perfect Roast Chicken

24 Safety a the top of the agenda Safety culture Clear information on safety and harm Walkabouts 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 briefings Improve rescue – Simulation, debriefing, RRT Secondary Drivers (Components & activities leading to 1º drivers) Handover (SBAR & Critical language) Photo boards Proformas for admission Driver Diagram Become a learning organisation Institute GTT SUI team Rapid reviews Debriefings Formal response to all/selected incidence forms Transparency On safety committee/team Ability to effect change Prescribing criteria Standardised medication guidelines Improve hand hygiene Surgical site infections

25 The Improvement Guide, API Aim Measures Changes Execution

26 The PDSA Cycle for Learning and Improvement What 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

27 Repeated Use of the Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA

28 Group Discussion 4 How might you achieve Harm Free Paediatrics where you work?

29 A few ideas we’ve tried… Situation awareness Communication Bundles Bring consultants to the front 24/7

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31 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

32 “Brighton” PEWS

33 PEWS: 24 PDSA Cycles in 9 Months

34 K

35 RFH PEWS Scores on 7 parameters Set actions according to score 0-1 Continue observations 2 Nurse in charge review 3 Above plus SHO review 4 Above plus inform registrar 5-7Registrar review +/- Crash call

36 SBAR Situation Background Assessment Recommendations

37 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

38 SBAR Modifications iSBAR – identification of yourself, your location and your patient. SBAR with a Readback – After handover give a readback of highlights

39 SBAR Notes 11 Essential components of a hospital note 1.Patient ID 2.Date 3.Time 4.Context 5.Situation 6.Background 7.Assessment 8.Recommendation 9.Signature 10.Print Name 11.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

40 Use data to drive Change Re-education and individual feedback Named consultantEducation and visual reminders 25/10/2012 Dr. John Fitzsimons - Presentation to National Clinical Leads

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42 “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.” Sir Liam Donaldson Questions welcome


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