parallel session 2.3.2 what's your problem? lessons on how to solve national and local...
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Safety Culture the journey in paediatrics – so far......
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Scottish Patient Safety Paediatric Programme
• Success of SPSP – adopted work streams.• SPSPP launched – June 2010• Inpatient paediatric care (all ages).• Aims:
– paediatric evidence-base;– ‘best in class’;– linked to measurable outcomes.
• Dynamic quality improvement programme.• Relevant to paediatric hospital care delivered in Scotland.
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SPSPP Key Aim: 30% reduction in adverse events by June 2013
“Harm” – anything done you wouldn’t
like done to yourself
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Defining the problem
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Measuring Harm – Paediatric Trigger Tool
Sep-09Oct-
09
Nov-09Dec-0
9Jan-10
Feb-10
Mar-10
Apr-10
May-10Jun-10
Jul-10
Aug-10Sep-10
Oct-10
Nov-10Dec-1
0Jan-11
Feb-110
20
40
60
80
100
120
140
per 1
000
patie
nt d
ays
Median = 0
Aim: 30% reduction in Adverse Events (measured by PTT) by June 2013
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What can we do with the data?
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Working with People
0%
20%
40%
60%
80%
100%
Adapted from R Scoville, R Lloyd, IHI
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Subject Matter Experts
Culture shift – understanding
of harm!
Triggers not applicable to
DGH care
Adverse Events
‘rare events’ – how to improve
Liked the multi-disciplinary approach to
reviews
Many triggers addressed by
SPSPP
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What are we trying to accomplish?
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The aim.....
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Testing / Change Concepts
• Methodology
• Review to follow admission
• Identify what causes harm / common system failures– Long-term conditions– Child Protection
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What change can we make that will result in improvement?
Is Avoidable Harm Indicator Present? y
n Was there harm?
y state grade
E-I
n Was harm preventable?
y n comments documentation missing
Did the child deteriorate? If yes... Failure to recognise? Highlight parental concerns
not actioned.
Failure to escalate? Escalation failure? Failure to adhere to standard practice
or local/national guidance?
Delay in administering treatment? If AVPU abnormal were full neuro obs
documented?
Was there an escalation of level of care, i.e. child admitted to HDU/PICU?
SPSPP Avoidable Harm - Structured Case Note Review
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How will we know a change is an improvement?
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Improvement Journey
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Cultural Shift – Adverse Events to Avoidable Harm
Support local quality improvement to reduce
avoidable injury and harm
Harm within wards
Measure
‘avoidable harm
Trigger Tool
Methodology