6. Measuring Harm – Paediatric Trigger Tool
Aim: 30% reduction in Adverse Events (measured by PTT) by June 2013
140
120
per 1000 patient days
100
80
60
40
20 Median = 0
0
8. Working with People
100%
80%
60%
40%
20%
0%
Adapted from R Scoville, R Lloyd, IHI
9. Subject Matter Experts
Triggers not
Liked the multi-
applicable to
disciplinary
DGH care
approach to
reviews
Culture shift –
Adverse Events
understanding
„rare events‟ –
of harm!
how to improve
Many triggers
addressed by
SPSPP
12. Testing / Change Concepts
• Methodology
• Review to follow
admission
• Identify what causes
harm / common
system failures
– Long-term conditions
– Child Protection
13. What change can we make that will result
in improvement?
SPSPP Avoidable Harm - Structured Case Note Review
Is Avoidable Harm Indicator Present? y n Was there y n Was harm y n comments documentation
state
harm? grade preventable? missing
E-I
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?
16. Cultural Shift –
Adverse Events to Avoidable Harm
Trigger Tool
Measure Methodology
„avoidable
harm
Harm
within
wards
Support local quality improvement to
reduce avoidable injury and harm
Editor's Notes
The purpose of this presentation is to attempt summarise a two and a half year journey into 30 mins and share with you the lessons we’ve learnt about how to measure harm and the development of a safety culture within the paediatric community in Scotland. What this won’t be is an academic presentation on the theory and practice of achieving a safety culture – but try to explain some of the elements that we’ve found that have influenced the development of SPSPP and where the programme has evolved. James Reason believes that ‘safety cultures evolve gradually in response to local conditions, past events, the character of leadership and the mood of the workforce’.
SPSPP launched in June 2010 – the first of it’s kind
Story of where we reached – Paediatric Trigger Tool – wasn’t applicable to care delivered in hospitals in Scotland
Low rates of harm seenMedian = 0 therefore “no useable data?” by run chart rules So we can all relax and stop worrying about improvement!
Has there been any point in the the trigger tool?Identifying common triggers to direct improvementPoor documentation of adherence with PEWS – are we missing sick children? Are we allowing children to deteriorate unrecognised in our care?
Redefining the purpose of case note reviews – linking it to the Safe Ambition and supporting the identification of avoidable harm at a local level.
Develop a methodology to measure harm in paediatric wards across NHSScotland - to support local quality improvement & reduce avoidable harm
Feedback – quicker / more relevant / finding issues
Feedback – quicker / more relevant / finding issues
