The document summarizes the Scottish Patient Safety Paediatric Programme (SPSPP), which aims to reduce adverse events in pediatric hospital care in Scotland by 30% by June 2013. The SPSPP uses a pediatric trigger tool to measure adverse events and identify areas for improvement. It takes a multidisciplinary approach including subject matter experts to conduct reviews of cases involving potential adverse events or avoidable harm. The goal is to test changes and improvements that address common causes of harm or system failures, and track metrics to know if the changes are leading to lower rates of avoidable harm.

1. Safety Culture the journey in
paediatrics – so far......

3. 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.

4. SPSPP Key Aim: 30% reduction in
adverse events by June 2013
“Harm” – anything
done you wouldn‟t
like done to
yourself

5. Defining the problem

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

7. What can we do with the data?

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

10. What are we trying to accomplish?

11. The aim.....

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?

14. How will we know a change is an
improvement?

15. Improvement Journey

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