![Page 1: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/1.jpg)
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
![Page 2: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/2.jpg)
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
![Page 3: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/3.jpg)
What is patient safety?
“The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”
Charles Vincent
![Page 5: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/5.jpg)
![Page 6: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/6.jpg)
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
![Page 7: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/7.jpg)
Errors of Omission
“On average, children received 46.5% of the overall indicated care”
“On average, children received 46.5% of the overall indicated care”
![Page 8: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/8.jpg)
Error & Harm
ErrorHarm
Non-preventable
Preventable
![Page 9: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/9.jpg)
Group Discussion 1
What makes paediatric patient safety different?
![Page 10: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/10.jpg)
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
![Page 11: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/11.jpg)
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
![Page 12: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/12.jpg)
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%
![Page 13: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/13.jpg)
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
![Page 14: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/14.jpg)
Group Discussion 2
What are the challenges for paediatric patient safety in a regional setting?
![Page 15: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/15.jpg)
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
![Page 16: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/16.jpg)
Group Discussion 3
What would a safe paediatric service look like in your hospital?
![Page 17: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/17.jpg)
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
![Page 18: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/18.jpg)
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
![Page 19: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/19.jpg)
First Steps
• Will, Ideas, Execution
• Have an aim – SMART
• Have a strategy – driver diagrams
• Have an improvement method - Model for Improvement
![Page 20: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/20.jpg)
SMART Aim
SpecificMeasurableAchievable
RealisticTime bound
Aim – “Improve hand hygiene”
![Page 21: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/21.jpg)
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”
![Page 22: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/22.jpg)
Primary Drivers(Processes, rules of conduct, structure)
Secondary Drivers(Components & activities leading to 1º drivers)Driver Diagram
Aim
![Page 23: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/23.jpg)
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
![Page 24: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/24.jpg)
Safety a the top of the agendaSafety cultureClear information on safety and harmWalkabouts
Improve safety on children’s wards
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
![Page 25: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/25.jpg)
The Improvement Guide, API
Aim
Measures
Changes
Execution
![Page 26: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/26.jpg)
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
![Page 27: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/27.jpg)
Repeated Use of the Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S DD S
P ADATA
![Page 28: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/28.jpg)
Group Discussion 4
How might you achieve Harm Free Paediatrics where you work?
![Page 29: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/29.jpg)
A few ideas we’ve tried…
• Situation awareness
• Communication
• Bundles
• Bring consultants to the front 24/7
![Page 30: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/30.jpg)
![Page 31: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/31.jpg)
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
![Page 32: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/32.jpg)
“Brighton” PEWS
![Page 33: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/33.jpg)
PEWS: 24 PDSA Cycles in 9 Months
![Page 34: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/34.jpg)
K
![Page 35: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/35.jpg)
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
![Page 36: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/36.jpg)
SBAR
SituationBackgroundAssessment
Recommendations
![Page 37: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/37.jpg)
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
![Page 38: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/38.jpg)
SBAR Modifications
• iSBAR – identification of yourself, your location and your patient.
• SBAR with a Readback – After handover give a readback of highlights
![Page 39: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/39.jpg)
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
![Page 40: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/40.jpg)
Dr. John Fitzsimons - Presentation to National Clinical Leads
Use data to drive Change
SBAR 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
om
pli
ance
Items
Bundle
Re-education and individual feedback
Named consultantEducation and visual reminders
25/10/2012
![Page 41: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/41.jpg)
![Page 42: Developing Safety Programmes in Regional Hospitals PSC & PIPSQC Paediatric Patient Safety Day Birmingham, May 20 th 2013 Dr. John FitzSimons HSE Ireland](https://reader030.vdocuments.mx/reader030/viewer/2022032516/56649c6f5503460f94921d84/html5/thumbnails/42.jpg)
“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”
Sir Liam Donaldson
“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”
Sir Liam Donaldson
Questions welcome