1. A New TRIC An audit tool for multi-patient environments An audit tool for multi-patient environments Sue Ieraci 2013

2. What’s the Issue? A simple formula:A simple formula: Focus on quality and safetyFocus on quality and safety+Risk-aversion+ Unsophisticated clinical governance toolsUnsophisticated clinical governance tools Sue Ieraci 2013

3. What do we have now? Some format/combination of: “Incident” reporting “Incident” reporting Severity coding Severity coding ‘’Incident’’ Investigation ‘’Incident’’ Investigation +/- Root Cause Analysis +/- Root Cause Analysis Implementation of recommendations Implementation of recommendations Implementation audit Implementation audit Sue Ieraci 2013

4. Anything wrong with RCAs? Just one tool Just one tool Assumes there is always a ‘’root cause’’ Assumes there is always a ‘’root cause’’ Looks at individual patient care Looks at individual patient care Linear, not contextual Linear, not contextual Focus on identifying errors Focus on identifying errors Doesn’t recognise an ‘’acceptable’’ error rate Doesn’t recognise an ‘’acceptable’’ error rate Recommendations often not reality-tested Recommendations often not reality-tested Sue Ieraci 2013

5. Acceptable complication rat Acceptable complication rates There is an accepted complication rate for: Surgical procedures Surgical procedures Central line insertion Central line insertion Therapeutic substances........ Therapeutic substances........ But NOT for COGNITIVE processes Sue Ieraci 2013

6. ‘’The London Protocol’’ SYSTEMS ANALYSIS OF CLINICAL INCIDENTS Clinical Safety Research Unit, Imperial College London Clinical Safety Research Unit, Imperial College London Beyond the RCA Beyond the RCA “Beyond the more usual identification of fault and blame.’’ “Beyond the more usual identification of fault and blame.’’ ‘’If the purpose is to achieve a safer healthcare system, then finding out what happened and why is only a way station in the analysis. The real purpose is to use the incident to reflect on what it reveals about the gaps and inadequacies in the healthcare system.’’ ‘’If the purpose is to achieve a safer healthcare system, then finding out what happened and why is only a way station in the analysis. The real purpose is to use the incident to reflect on what it reveals about the gaps and inadequacies in the healthcare system.’’ Sue Ieraci 2013

7. Why something different for EDs? THE MULTI-PATIENT ENVIRONMENT Multiple patients with competing interests Multiple patients with competing interests Prioritisation and compromise inevitable Prioritisation and compromise inevitable Interruption and multi-tasking Interruption and multi-tasking Concurrent vs sequential patients Concurrent vs sequential patients Undifferentiated patients Undifferentiated patients Team-input to process and outcomes Team-input to process and outcomes Patient journey Patient journey Everyone else has hindsight Everyone else has hindsight Sue Ieraci 2013

8. Proposed methodology TEAM REVIEW IN CONTEXT Principles: Examine the performance of the clinical team, in the context of the ‘’episode ’’ Examine the performance of the clinical team, in the context of the ‘’episode ’’ Use only the information available at the time (no benefit of hindsight) Use only the information available at the time (no benefit of hindsight) Consider whether the team-members involved in the complex event made either cognitive or prioritisation errors with the resources and completing demands existing at the time Sue Ieraci 2013

9. Components of the tool 1.Task complexity analysis / Process mapping 2.Prioritisation analysis 3.Cognitive analysis 4.Improvement potential analysis 5.Reality testing of recommendations 6.Conclusion Sue Ieraci 2013

10. Task complexity analysis / Process mapping identifies the entire scope of the competing demands for care that were occurring during the episode identifies the entire scope of the competing demands for care that were occurring during the episode and and maps the care pathways of individual patients maps the care pathways of individual patients Sue Ieraci 2013

11. Prioritisation analysis Examine competing priorities according to urgency of time-criticality for intervention Examine competing priorities according to urgency of time-criticality for intervention and and assesses whether there may have been avoidable errors in prioritisation that have impacted on patient outcomes assesses whether there may have been avoidable errors in prioritisation that have impacted on patient outcomes Sue Ieraci 2013

12. Cognitive analysis evaluation of the clinical decisions made by the individuals involved in the episode evaluation of the clinical decisions made by the individuals involved in the episode using only the information available at the time using only the information available at the time to look for any avoidable cognitive errors to look for any avoidable cognitive errors Croskerry Sue Ieraci 2013

13. Improvement potential analysis Could any any aspect of care potentially be sustainably improved within realistic resources? Could any any aspect of care potentially be sustainably improved within realistic resources? Sue Ieraci 2013

14. Reality testing of recommendations Would any proposed recommendations realistically have changed the outcome? Would any proposed recommendations realistically have changed the outcome? Are they are realistically achievable? Are they are realistically achievable? Could they cause unintended consequences? Could they cause unintended consequences? Sue Ieraci 2013

15. Conclusion Summarises the findings of the process It is an acceptable option to conclude that no recommendations arise as a result of application of the tool. Sue Ieraci 2013

16. Other essential features At least one team-member present at the time of the episode is on the team At least one team-member present at the time of the episode is on the team Team members are only given information that was available at the time Team members are only given information that was available at the time The application of the tool should be recorded in the order of the steps specified above, so that each component flows logically into the next, and into a conclusion. The application of the tool should be recorded in the order of the steps specified above, so that each component flows logically into the next, and into a conclusion. Sue Ieraci 2013

17. Acknowledgements Cognitive collaborators Philip Hoyle – Clinical governance Deniz Tek – Cognitive error and cognitive autopsy Spiritual Collaborators All those people who have suffered the consequences of inappropriate or poorly-executed RCAs Sue Ieraci 2013

18. A NEAT TRIC! Sue Ieraci 2013