Dr. John FitzSimons HSE Ireland Dr. Santanu Maity Royal Free Hospital, London

1. Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety DayBirmingham, May 20th 2013 Dr. John FitzSimons HSE Ireland Dr.SantanuMaity 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…

6. Organisational Accident Model Organisation & Culture Contributory factors Care delivery problems Defences & Barriers Management decisions & Organisational processes Environment factors Team factors Staff factors Task factors Patient factors Unsafe acts Errors Violations Harm Active failures Latent failures

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

8. Error & Harm Non-preventable Preventable

9. Group Discussion 1 What makes paediatric patient safety different?

10. Patient FactorsUnique Features of Paediatric Care

11. System Factors

12. NPSA Safety incident reports(Children Vs Adults)

13. Safety Solutions “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 • No, or the very least, pain or distress. • No unnecessary investigations or admissions or treatments. • No tissue injury - extravasation, pressure or other. • No hospital acquired infections. • No medication or fluids injuries. • Recognise sepsis or other life threatening events as early as possible and institute the right treatment. • 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. Secondary Drivers (Components & activities leading to 1º drivers) Driver Diagram Primary Drivers (Processes, rules of conduct, structure) Aim

23. Crispy Skin Moist meat flavoursome Perfect Stuffing Great Gravy Good Presentation Secondary Drivers (Components & activities leading to 1º drivers) Driver Diagram Primary Drivers (Processes, rules of conduct, structure) Basting Seasoning Heat Brining Slow & low cooking Organic chicken Herbs Components – Chestnuts, bread Volume Stock Wine flavourings The Perfect Roast Chicken Dressing Plates

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

25. Aim Measures Changes Execution The Improvement Guide, API

26. The PDSA Cycle for Learning and Improvement What change can we make that will result in an improvement ? Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize • what was • learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

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

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

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 5-7 Registrar 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 • Patient ID • Date • Time • Context • Situation • Background • Assessment • Recommendation • Signature • Print Name • 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 Education and visual reminders Named consultant Re-education and individual feedback Dr. John Fitzsimons - Presentation to National Clinical Leads

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