Don’t need to preach to the converted here at this meeting…..
Patient safety is addressed and discussed from many perspectives…..industry, aviation, ergonomics, engineering etc.
Warren start here
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Together + Q&A
A2: Perioperative Power Point - Denise Hudson
“Less is More”Simplified Perioperative BC PSLS Reporting Denise Hudson, BC PSLS Warren Hill, BCCH
The problem• Under-reporting of patient safety events in the perioperative suites• Length of time to complete a report form• Low reporting rate by health care team members other than Nursing• Insufficient information on form to guide follow-up response
Aim statementTo increase reporting of hazards, near missesand patient safety events to the BC PatientSafety & Learning System by staff in theperioperative suites at BC Children’s Hospitalby 10% by March 7, 2012
Proposed changes• Shorten the PSLS report form• Ask fewer questions• Eliminate some drop-down fields (e.g. categorization of event)• Prompt for more narrative information• Clarify “near miss” and “potential for harm” questions• Add options for feedback to reporters
Process• Met with focus groups• Drafted sample form and vetted with group• Developed new form and implementation plan with BC PSLS Central Office• Communicated through email, posters, safety rounds
What we thought would happen• Decreased time for reporter to complete form• Increased number of reports from staff other than nurses• Better understanding of follow-up needs of reporters• Clearer distinction of actual from potential patient harm• Increased number of events reported• Increased satisfaction of staff with the safety reporting process
What we found after 60 days• Time to complete form ~5.5 mins; 45% reduction• 33% increase in physician-generated reports• Event follow-up expectations were clarified and helped to triage event follow-up• 93% reduction in anonymous reports• Average # of words in event description remained almost the same (53 pre vs. 55 post)• Slightly increased handler time needed for post- event classification• Reporting volume declined by 11%
Requests for follow-up• No (31%)• Yes - Contact me about this event as soon as possible (4%)• Yes - Would like an update when follow-up is complete (65%)
Preventing severe harm• New form asks the reporter if there was potential for severe harm• Identifying the potential for severe harm helps to prevent future actual harm• 100% of physician-generated reports using new form described potential for severe harm relating to the incident (cf. 10% using old form)
Examples of potential harm given•Air embolus, leading to cardiovascular collapse, possible cardiac arrest, possible death•All events and procedures for child could have been on the wrong patient•If he had been unable to cough his secretions out, and I was not able to suction him ina timely manner, he could have experienced severe respiratory compromise•If screw had fallen into the open mastoid bone and not noticed, patient would havebeen left with a foreign object in body!•If the patient didnt have an ID bracelet on there is a potential that the wrong patientwas operated on, and also there was no consent with the patient•Paralysis•Could have become hypoxic, drop in O2 saturation, delay in ability to support airway•Prolonged apnea requiring possible PICU admission and ventilation•Septic - could have become increasingly sick without notice.•Skin necrosis due to pressure in the prone position for 2.5 hours•We might have hooked up the IVs to the wrong patient, thereby infecting him(the pt,also did not have ID bands on, but that is a separate PSLS!)•We were not told in handover that the patient had allergies to penicillin. We nearlyconnected up the wrong IV pumps to this child.
Safety event reporting surveySample automated reply to reporter:Privileged & Confidential - For Quality Assurance Purposes Only.You have submitted a Patient Safety Event Report via the PHSA BC PSLS system with the followingdetails:PSLS Event ID: XXXXXXDate of Event: 21/02/2012Handler:Please click here to fill out a quick survey about safety event reporing in the BC ChildrensPerioperative Area.Thank you for your commitment to safety!By recognizing, reporting, and acting on safety hazards, events and situations, you are helping toimprove the quality of care for our patients, residents, clients, and staff, and to foster a culture ofsafety. Your report assists in identifying and analyzing system challenges and other opportunities forimprovement.For more information, please contact your immediate supervisor, using the PSLS Event ID provided.
Survey results: New form ratingCompared to the "old" PSLS report form, how would yourate the following aspects of the "new" form? Much Slightly No RatingAnswer Options Worse N better better change AverageLength of the form 24 1 0 0 1.04 25Clarity of questions 18 6 1 0 1.32 25Usefulness of "help" 15 4 2 0 1.38 21and examples
Survey results: Less is moreWere the questions on the new form detailed enough to help you provide all important information? 4.0% Yes No 96.0%
Survey results: Satisfaction Overall, how satisfied are you with the new form? 0.0% 32.0% Very satisfied Satisfied 68.0% Not satisfied
Survey results: Comments• Love options to have follow-up or not• Shorter form will encourage reporting• Simplified form is user-friendly, quick to fill out, less wasted effort• Clearer, more clinically-relevant questions (e.g. degree of harm), better explanations• It is a very appropriate system with exceptional follow-up in my experience• Keep encouraging staff other than nursing to report
Project limitations• Short window of time for comparison may not reflect actual trends (i.e. 60 days pre- and post- implementation)• Tested during holiday period when regular staff are often away, activity level is reduced• Recruitment bias in survey and advertising• Pilot-tested in one area - may not necessarily be generalized to other units/areas• Difficult to determine impact of significant quality improvement initiative on reporting volume
Summary of findings• Reporters much prefer simplified form and options for follow-up• Reporting from physicians has increased• More accurate distinction between actual and potential harm (detected events at “no harm” level without false alarms)• Simplifying form did not increase report volume• Incident follow-up is essential to success• Asking reporters how they want to be involved in follow-up fosters commitment to safety culture
Suggested improvements• Reduce date/time questions and auto-populate fields where possible• Consider automated email feedback to reporters when follow-up is completed• Offer more education on safety event reporting• Standardize process for follow-up• Make information gathered more clinically relevant and less administrative
Next steps• Revise form to incorporate feedback• Share with others to determine potential for wider implementation• Assess follow-up pathways and address workload for administrative data collection (if reporter doesn’t fill it out, who will?)• Check results at regular intervals (PDSA)
Thanks!• BCCH perioperative nurses, physicians and staff• BC PSLS Central Office Team Annemarie Taylor Michelle Preston Inderpal Chani• BCCH Quality and Safety Leaders
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