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20/04/2015
1
A Multi-Disciplinary Team Approach to Safety
J Martin, R Isaac
March 2015
"Conflict of interest: nothing to disclose”
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Questions
1. Do you understand the benefits of a multi-disciplinary/multi-level approach to safety? (yes/no)
2. Do you understand the benefits and drawbacks of an incident reporting system? (yes/no)
3. Are you aware of the MERP classification system for medication incidents? (yes/no)
Introduction
• History of Safety on BCH PICU
• Safety Culture on BCH PICU
• Governance Process and the Multi-Disciplinary
Team
• Examples of Incidents & Lessons Learned
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History of Safety on BCH PICU
BCH PICU• 29 beds currently (31 by end of the year)
• 1400-1500 admissions per year (7-8% of UK PIC)
– 55% admissions from BCH, 45% from other hospitals
• Closely linked with KIDS
• Case mix:– 40-50% congenital cardiac disease (80% planned
admissions)
– ECLS service since 2008
– all specialties, nationally commissioned SB/OLTx
• 85% admissions require invasive ventilation
• average bed occupancy 92% past 12 months
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Once upon a time ……
• 2004 deaths were not accurately counted or examined
• Hospital acquired injury and infections were considered normal complications of ICU stay
• Predictable, avoidable, preventable were not in our vocabulary
• Measured admission numbers only………
What’s in our current safety package?
• Incident Reporting– medication incidents
– emergency events
– unplanned extubations
– extravasation
• Healthcare Associated Infections
• Morbidity & Mortality
• Unplanned readmissions within 48hrs
• Culture
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Our Journey
• 2008
– medication errors recognised as most common incident reported on PICU
– ‘PICU Medication Incident Group’ established
– MI form designed to gather specific data
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Our Journey
• 2009
– increased MI reporting, but also increased IR1 reporting in general
– PIC MI Group expanded to look at all incidents -‘PICU Safety Group’
0
20
40
60
80
100
120
140
160
Nu
mb
er
of
Inci
de
nts
Month
PICU Incident Reports Over Time
All Incident Reports
Medication Incidents
PICU Medication Incident Group formed
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Our Journey• 2009
– specific reporting expanded to include unplanned extubations and all emergency events (buzzer pulls/calls for help)
– aim to identify predictable and/or preventable factors
• 2010– Trust-wide extravasation audit
• 2011– Trust-wide electronic IR1 system
• 2014– separate Medication Group re-established– use of MERP to classify Medication Incidents
Safety Culture on BCH PICU
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Accidents?
fate, predestination, God’s will, witchcraft, broken taboos
(scientific revolution , 17th century)
accidents, meaningless coincidences, random, uncontrollable
(mid-1970s)
evidence of mis-managed risk- who’s responsible, who’s to blame, criminalisation
Reporting Errors1. Report?– get in trouble, stigmatised, reprimanded, fired,
prosecuted?
– what is the organisation going to do?
– media reporting
2. Don’t report?– fingers crossed no-one else reports/finds out
even worse trouble if found out
– non-disclosure makes a normal mistake look dishonest, with the result it is often treated as such
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What About Accountability?• blame culture no blame culture
• but surely we are responsible for our actions?
• should we not be able to offer an account for our actions?
• what to patients involved in an incident want?– honesty
– an apology
– reassurance actions taken so the same thing won’t happen again to others (learning, improved safety)
– compensation
Good Medical Practice‘If a patient under your care has suffered harm or distress, you must act immediately to put matters
right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-
term effects’
‘Patients who complain about the care or treatment they have received have a right to expect a prompt,
open, constructive and honest response including an explanation and, if appropriate, an apology. You must
not allow a patient’s complaint to affect adversely the care or treatment you provide or arrange’
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‘Fair-Accountability’ Culture
Blame No Blame ‘Fair-Accountability’
• encourage reporting, discourage blame
• identify systems/process issues that allow/encourage human error
• encourage critical self-evaluation (vs. self-blame) - satisfies demands for accountability
• considerate and understanding incident investigation, provide staff support, take care of the ‘second victim’
• offer training/re-training if required
• confidentiality
• provide feedback (individual, departmental, wider)
• allows the organisation to invest in improvements for safety, rather than resource legal protection & limiting liability
• enables learning/improvement so probability of future harm decreases
Governance Process and the Multi-Disciplinary Team
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Incident Investigation
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Incident Feedback
• key to: – active reporting culture
– dissemination of learning/improving safety
– reducing complaints!
Incident Classification
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Severity
Likelihood
InsignificantAcceptable
management
MinorUnacceptable
management but no adverse outcome
ModerateModerate
Mismanagement of patient care with adverse outcome
MajorSerious
Mismanagement of patient care with an
adverse outcome
CatastrophicDeath
RareNot in next 5 years
1 2 3 4 5
UnlikelyOnce in every 3 to 5
years
2 4 6 8 10
PossibleOnce or twice a
year
3 6 9 12 15
LikelyOnce or twice a
month
4 8 12 16 20
Almost Certain More
than once a week
5 10 15 20 25
Risk Score
0
10
20
30
40
50
60
70
80
90
Pe
rce
nta
ge
Month
Risk Score of PICU Incidents
Percentage of Incidents Scoring > 6
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Incident Classification
Actual Impact
• represents the actual outcome to the patient irrespective of the level of risk/error
1 - No harm
2 - Minor, non-permanent harm (up to 1 mth)
3 - Moderate, semi-permanent harm (up to 1 mth)
4 - Severe, permanent harm
5 - Catastrophic, death
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Incident Classification
Avoidable Harm
• avoidable harm:– harm that could potentially have been prevented had
an error not occurred
• error:– when a planned sequence of mental or physical
activity fails to achieve its intended outcome (JReason)
• harm:– subjective and therefore potentially controversial use US National Coordinating Council for Medication
Error Reporting and Prevention (MERP) definition:
‘Impairment of the physical, emotional, or psychological function or structure of the body
and/or any resulting pain’
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Avoidable Harm
• MERP definition covers quite minor harm through to much more severe harm
• important to note that this definition does not include a time period– harm can be said to have occurred even if time period over
which it lasts is very short (e.g. < 1min)
• Example:– morphine overdose leads to apnoea which requires bagging
– resuscitated appropriately, naloxone given
– very unlikely the patient would suffer any permanent harm, but the cessation of breathing is in itself harm as defined by temporary ‘impairment of the physical function (breathing) of the body’
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21
29
33
21
26
30
33
30 30
25
20
2625
19
01 1
0 01
01
21
01
01
0
5
10
15
20
25
30
35
Nu
mb
er
of
MIs
Month
Medication Incidents by MERP Classification
MERP A-DMERP E-I
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03,3 2,9
0 03,2
03,2
6,3 40
3,7
0
10
20
30
40
50
60
70
80
90
100
Pe
rce
nta
ge
Month
MERP E-I as a Percentage of all MIs
332, 28%
170, 14%
170, 14%
70
49
46
44
37
36
33
30
29
25
24
23
23
16
11
11
11
9
4
2
1
1
0 50 100 150 200 250 300 350
Medication
Emergency Event
Equipment
Patient Care & Monitoring
Unplanned Extubation
No Incident/Error/Duplicate Report
Tissue Viability - Extravasation
Documentation
Communication
Staff Injury/Accident/Needle Stick/Blood splash/Manual…
Abuse/Security
Tissue Viability - Pressure Sores/Other
Feeds
Blood Products
Environmental Safety/Estates/Fire/IT/food
Incident cause/source external to PICU
Capacity
Hospital Incurred Trauma (Not Extravasation)
Arterial Line
Other
Staffing
Child Protection
Visitor Injury/Collapse
Delayed Discharge
Transport - Intrahospital
Number of Incident Reports
Inci
de
nt
Re
po
rt T
ype
PICU Incident Reports by Type 2014
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0
5
10
15
20
25
30
35
40
45
50
Nu
mb
er
of
Inci
de
nts
Month
Prescription vs Administration Incidents
Total Medication Incidents
Prescribing Incidents
Administration Incidents
Administration; 146; 44%
Prescribing; 68; 20%
Other; 53; 16%
Documentation; 46; 14%
Labelling; 16; 5%Equipment; 3;
1%
Medication Incidents by Group 2014
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Incomplete/Unclear; 26; 38%
Overdose Prescribed; 18; 26%
Drug Protocol/Guidance
Not Followed; 9; 13%
Prescription Unintentionally
Omitted/Prescribed Late; 6; 9%
Underdose Prescribed; 5; 7%
Wrong Frequency; 2; 3%
Wrong Route; 1; 2% Duplicate Drug/Drug Type; 1; 2%
Prescription Incidents by Type 2014
Problems with Incident Reporting
• depends on staff reporting– if an error is perceived to occur, or
– because outcome it catastrophic - e.g. death
• evidence suggests that IR systems only pick up 7-15% of errors
• IR system call give a wealth of information, but:– no doubt not all errors are reported
– difficult to monitor improvement
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Medication ‘Safety Thermometer’• principles:
– point prevalence data collection– all inpatients, 1x/month– efficient tool - < 10 mins per patient– joint nurse and pharmacist data collection– at bedside
• involve bedside nurse and patient/family• prompts immediate action if required
– collects information on errors, particularly involving high risk drugs with possible harm
• benefits over incident reporting:– objective measure, not reporter dependant– gives denominator data– useful for monitoring trends & impact of interventions
Under 18 25-44
45-59 75 or Over
0 5 - 9
10 - 14 More than 20
Anticoagulant
Opioid
Insulin
Anti-infectives2
Any other prescribed medicines
1.6a Please tick below which
medicines the patient has been
prescribed .
1.6b If any have been omitted in the
last 24 hours please tick all reasons
that apply for each
Valid
Clin
ical R
eason (
eg low
BP
)1
Medic
ine n
ot
availa
ble
Route
not
availa
ble
1.3 Is the medicine allergy status
documented in your clinical record in
this care setting?
1.4 Was medicines reconciliation for
all medicines undertaken (started) by
the pharmacy team within 24 hours
of admission to this care setting?
Pharmacist or medicine management technician has
been involved
Patient
Refu
sed
Outs
tandin
g R
econcili
ation
Not
Docum
ente
d
Reasons for Omission
Patient
absent
at
med r
ound
Oth
er
Anticoagulant IV/SC Sedatives
Opioids Insulin
1 - 4
15 - 19
Excluding food supplements & O2
(including no known drug allergies) e.g on prescription
or MAR sheet
No
1.5 How many regular medicines is
the patient prescribed?
Excluding PRN, Stat doses, IV fluids, O2, food
supplements or devices. Different doses of the same
medicine count as one medicine
Medications Safety Thermometer - Acute Collection Form V16
Ple
ase c
ircle
an
sw
ers
SE
CT
ION
1 T
his
section s
hould
be c
om
ple
ted b
y the n
urs
e o
r prim
ary
care
r usin
g the m
edic
ation a
dm
inis
tration o
r pre
scription
chart
, in
form
ation fro
m c
linic
al re
cord
s a
nd d
ialo
gue w
ith the p
atient / care
r. T
he focus o
f th
is s
ection is o
n the fundam
enta
ls o
f
safe
medic
ation u
se. It s
hould
be c
om
ple
ted for
ALL p
atients
surv
eyed. E
ach q
uestion s
hould
be a
nsw
ere
d b
y c
irclin
g the
response o
r th
e b
ox c
om
ple
ted a
s r
equeste
d.
Yes
1.7 Has the patient received any of
the following medicines in the last
24hrs? (If yes circle medicines that
apply)
Anticoagulants (Heparin, LMWH, Warfarin and
NOACs3){Excluding VTE Prophylaxis}, Opioid
(excluding oral codeine, dihydrocodeine and
Tramadol), IV or SC Sedatives4, Insulin
If YES to Q1.7 proceed to Section 2 (If NO then form is complete)
No
No Patient still within
24 hour period at
point of survey
Yes
Specialty:
1.1 Gender:M
F
1.2 Age:
Number:
18- 24
60-74
Setting:
'Harmfree'care
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Date:Auditor (print name):1 According to local guidance.2 Anti-infectives (antibiotics, antifungals, antivirals & antimalarials).3 (Warfarin, Acenocoumarol (SINTHROMEO), Phenindione, Novel Oral Anticoagulants (NOACs), Dabigatran ( PRADAXA) Apixaban (ELIQUIS), Rivaroxaban (XARELTO) LMWH: Dalteparin (FRAGMIN),
Tinzaparin (INNOHEP), Enoxaparin (CLEXANE).4 IV or SC Sedatives Midazolam, Lorazepam, Diazepam, Clonazepam.
Does the patient show signs of common complications (capillary blood sugar <4mmol/L) or
symptoms of hypoglycaemia? If Yes which Trigger of Harm?
Complications / Reversal agent given /
DKA or HHSHas the patient had an administration of a reversal agent for hypoglycaemia (10-50% IV
Dextrose, Glucagon)?
Is the patient in Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycaemic State (HHS)? None of these
Symptoms of hypoglycaemia include: anxiety confusion, extreme hunger, fatigue, irrab ility, sweating or clammy skin, trembling hands
SE
CT
ION
2
Only
com
ple
te s
ection 2
if
a p
atient
has r
eceiv
ed a
n A
nti
co
ag
ula
nt,
Op
ioid
,
IV/S
C S
ed
ati
ves or
Insu
lin in t
he p
ast
24 h
ours
as a
nsw
ere
d in q
uestion 1
.7.
Only
answ
er
the c
orr
espondin
g q
uestions t
o t
he m
edic
ation t
hat
the p
atient
has r
eceiv
ed. D
ata
can
be
co
llecte
d b
y n
urs
ing
sta
ff,
med
icin
es m
an
ag
em
en
t te
ch
nic
ian
an
d p
harm
acis
t.
2.1 Anticoagulants (Heparin, LMWH, Warfarin & NOACs)
Ple
ase c
ircle
th
e r
ele
van
t an
sw
ers
on
ly
Has the patient had a bleed of any kind or a VTE? If Yes which Trigger of Harm?
Has the patient had an administration of Vitamin K, Protamine or clotting factors e.g.
Octaplex?Bleed / VTE / VIT K or other / INR > 6
Does the patient have an INR greater than 6 or APTT ration greater than 4?
2.4 Insulin
Has the patient had an administration of Naloxone? If Yes which Trigger of Harm ?
Is the patient's respiratory rate below 8 breaths per minute (bpm)?
Naloxone / bpm less than 8
None of these
2.3 Injectable Sedatives (Midazolam, Lorazepam, Diazepam, Clonazepam)
Has the patient had a common complication of over sedation which includes hypotension,
delirium, respiratory depression, reduced GCS?If Yes which Trigger of Harm?
Has the patient had an administration of reversal agent Flumazenil?
Common complications / Flumazenil
None of these
None of these
2.2 Opioids
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Multi-Disciplinary Team
Multi-Disciplinary Team• Multi-disciplinary:
– improves effectiveness of investigation• prescription, administration, consequences
• root cause and other contributory factors
– improves feedback
• Multi-level:– not just top-down promotion of safety-related changes
– safety champions in different areas• medical, nursing, pharmacy
• ‘post-heroic’ model of leadership, ‘leaders at many levels’ (J Turnball)
– junior nursing staff go onto other roles taking expertise with them
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Practical Steps
• encourage/increase incident reporting– on it’s own, little benefit
– has to be combined with learning, feedback & actions
– considerate and understanding incident investigation
• need a dedicated multi-disciplinary, multi-level team (invest time/staff/funding) - ‘leaders at many levels’
• you can only change what you measure– get (keep) access to your data
– make sure you manage what you measure
• need strong organisational & management commitment
• consider a point-prevalence measure of error/harm
“You can’t change culture, you can only change individual behaviours, and the only people who
can change an individual’s behaviours is themselves, and the only reason they will
change is if you give them a reason to do so” (Simon Dodds)
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Questions?
Putting It Into PracticeCase 1
• Patient A admitted to ward following large cyst removal
• Prescription for epidural ropivacaine via anaesthetist
• 50ml epidural syringe running out every 5 hours
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Case 1- Drug Preparation
• Epidural replaced by ward nurse at 11.30 but into 100ml syringe for time saving
• IV omeprazole for patient A due same time-prepared and administered.
• Nurse buddy off ward in meeting, calls another to check.
• Epidural missing label, nurse buddy fetches and completes.
Case 1- Realising Error
• 15:00 Patient A nurse due to give IV linezolid to patient B
• Nurse realises IV linezolid used for the epidural preparation for Patient A 3.5 hours earlier.
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So where did the error occur?
The Investigation
• Why was the wrong drug selected for the patient?
• Could this happen again?
– How likely?
– How can we stop it happening again?
• What lessons can we learn from this error across the Trust?
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Who was there at the RCA?
• Chair
• Anaesthetics/ pain team
• Surgeon/ patient consultant
• Ward manager/ nursing manager area
• Independent nurse
• Education Team
• Risk Manager
• Primary care provider representatives
• Pharmacist
Why was wrong drug selected?
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The boxes are different
The additive ports are different
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Pain team- can I open the bag?
Crime scene walkthrough with MDT
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Medicines Policy
Section on administration of parenteral drugs
1.) Bedside nurse anticipates epidural will need replacing
2.) Bedside nurse advises buddy need for drug checking support.
3.) Bedside nurse collects all for drug preparation. Epidural sought from the “epidural only” shelf
4.) Both nurses check all for drug preparation. Includes right drug, right concentration, right route of administration, right patient and in date.
5.) Bedside nurse prepares drug according to prescription. And is checked by buddy.
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How do you double check?
Hold that thought
1.) Bedside nurse anticipates epidural will need replacing
2.) Bedside nurse advises buddy need for drug checking support.
3.) Bedside nurse collects all for drug preparation. Epidural sought from the “epidural only” shelf
4.) Both nurses check all for drug preparation. Includes right drug, right concentration, right route of administration, right patient and in date.
6.) Buddy/checker prepares label for epidural and bedside nurse checks.
5.) Bedside nurse prepares drug according to prescription. And is checked by buddy.
7.) Syringe containing drug taken to patient, double checked against prescription/ patient name and admsinitrered
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1.) Bedside nurse supported by student. Informed when epidural ran out.
2.) Buddy in meeting-needs to find another to check.
3.) Bedside nurse collects all for drug preparation. Linezolid stored on epidural shelf.
4.) Second nurse checks but cannot recollect seeing drug name, only the 2mg in 1ml concentration and that it was in date.
6.) Label not completed.
5.) Bedside nurse selects larger syringe due to frequency of epidural change
7.) At bedspace 2nd nurse realises label not done and completes (without batch number as bag thrown), policy not to retrieve from sharps bin
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Contributory Factors
• Complex work on ward resulting in distorted perception of reasonable workload.
• Misled by superficial similarities in 2 drugs.
• Distracted by knowledge of IV and epidural preparation against policy.
• Patient in pain adding pressure to needing medicine quickly.
So what have we done
• Ward pharmacists and safety link nursing staff checked drug storage facilities across the whole hospital
• Rearrange storage where needed across the whole hospital
• Linezolid dispensing changes
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Pain Team/Anaesthesia
• Pumps changed
– No longer take syringes.
• Audit use of yellow lines/ epidural labels
• Considered centralising epidural stock
– Unworkable/ not practical
Workload on Ward
• CIVAS
– Other options
• MDT review to simplify regimens
• IV to oral switch
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205.5 324.2
337.3
359.3
382.3
394.3472.8
BCH Test Lin 2 diluted.d: +MS, 1.2-2.0min #(99-157)
130.7
275.7
BCH Test Rop 2 diluted.d: +MS, 0.8-1.2min #(62-98)
205.5
217.2
324.2
337.3
359.3
382.3
394.3
440.6
BCH Test unknow n.d: +MS, 4.4-4.6min #(341-359)
0.0
0.5
1.0
1.5
6x10
Intens.
0
1
2
3
4
5
6x10
0
1
2
3
4
5
6
5x10
150 200 250 300 350 400 450 m/z
Linezolidm/z 337
Ropivacainem/z 275
Unknown (syringe)
Experimental detail.Infusion of 1:10,000 dilution of standard drugs and unknown. Flow rate 3ul/min. Data collected on Brucker HCT Ultra in positive ion electrospray mode. Blanks run between samples showed no cross contamination.
Top spectrum shows a peak for linezolid from the standard at m/z 337.3. Other peaks are artefacts from the other excipients.
Middle spectrum shows a peak for ropivacaine from the standard at m/z 275.7.
Bottom spectrum is for the unknown from the syringe, which perfectly matches that for linozelid.
(further confirmation of drug identity was obtained by MSMS fragmentation – data not shown)
Governance
Checking all actions points completed
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Areas of good practice from Incident
• Escalation of incident– Advice and assistance from outside teams e.g
neurosurgey/ radiology/ poisons unit
• Patient pain relief
• Prompt and open discussion with family– And follow up
– Further questions following RCA
Case 2- PICU
15/03/2015
00:00
Gentamycin dose prescribed for 15/03/15 at 00:00 and signed for, on ward round noticed dose shouldn't have been given until 16/03/15 at 00:00 as doses were 36 hourly. Level and hold prescribed for 16/03/15 at 10:00 consultant aware and has explained to parents.
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Case 2- Local Issue
Gentamicin Levels
• Gent level on 14/3 12:00 @ 36 hourly dosing– 0.7mg/L
• Gent level on 15/3 00:01 @ 12 hours post dose– 3.5mg/L
• Gent level on 16/3 @10:00 @ 34 hours post dose– insufficient sample
• Gent level on 16/3/ @ 17:00 @ 41 hours post dose– 0.4mg/L
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How many think:
1. Prescribing error
2. Administration error
3. Both prescribing and administration error
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1.) Does my junior doctor have a knowledge gap or is it a lapse?2.) Is he aware of the gentamicin guideline for the Trust?3.) He’s just pointed out the guideline is different to the BNFc- why is this?4.) Will this be toxic- ask my pharmacist
1.) What was the gentamicin level at 36 hours? Let’s do some PK calculations to see if toxic and inform next steps2.) Does 00:00 mean morning or night of the 15/3/15? Does the Dr know- ask my consultant. Prescriber asked why is guideline different to BNFc- why is this?3.) Have the gentamicin audit forms been completed? Need to check with Sister
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1.) Does 00:00 mean midnight on 15/3/15 or the morning?2.) Why is BNFc dose different to guideline?2.) Pharmacist asked, ‘Have gentamicin audit forms been completed?’ Folder missing from drug room.
So what did we do next?
• 24:00 vs 00:00
– Use safety huddle communication strategy
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Yes, you do have to invest time.How we are doing it in pharmacy BCH
Some of Team PICU
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Team PICU Pharmacy
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PILOT- Extending Hours on PICU
• Clinical pharmacist on PICU from 8.30 until 18.30 Monday to Friday
• 2 month pilot
• Intervention records
• Queries by PICU staff: 395 (252 by nursing staff, 143 by prescribers)
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Prescribing assessment- this is how we want it done at BCH
How do you work with your team to improve safety?
What we learn from one another?
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Questions
1. Do you understand the benefits of a multi-disciplinary/multi-level approach to safety? (yes/no)
2. Do you understand the benefits and drawbacks of an incident reporting system? (yes/no)
3. Are you aware of the MERP classification system for medication incidents? (yes/no)
Answers1. Benefits of a multi-disciplinary/multi-level team
approach:
– improves effectiveness of investigation
– improves feedback
– not just top-down promotion of changes
– safety champions in different areas (‘leaders at many levels’)
– junior staff take expertise with them
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Answers
2. Benefits
– wealth of data
– wealth of learning from incident investigation
– use as guide to safety/quality improvements
– level of reporting is a guide to your safety ‘culture’
Drawbacks
– subjective, entirely reporter dependant, only know about what’s reported
benefit from regular objective point prevalence error reporting system
Answers
3. The MERP (Medication Error Reporting and Prevention) classification is a standardisedmethod of categorising medication incidents, in particular with regard to the severity of any harm which may have occurred