parallel session 2.3.2 what's your problem? lessons on how to solve national and local...

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

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.

SPSPP Key Aim: 30% reduction in adverse events by June 2013

“Harm” – anything done you wouldn’t

like done to yourself

Defining the problem

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

What can we do with the data?

Working with People

0%

20%

40%

60%

80%

100%

Adapted from R Scoville, R Lloyd, IHI

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

What are we trying to accomplish?

The aim.....

Testing / Change Concepts

• Methodology

• Review to follow admission

• Identify what causes harm / common system failures– Long-term conditions– Child Protection

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

How will we know a change is an improvement?

Improvement Journey

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