safety first principles of safe practice · why do we do it? risk management what goes...
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SAFETY FIRST – PRINCIPLES
OF SAFE PRACTICE
BMUS – General Medical Ultrasound
Saturday 15th September, 2018C P GRIFFIN
OVERVIEW
Governance
Protocols and Policies
Ergonomics
Health, Safety & Good Practice
Transducer Cleaning
The formal definition:
“A framework through which NHS organisations are
accountable for continuously improving the quality of their services and safeguarding high standards of care by
creating an environment in which excellence can flourish.”
The new NHS: Modern. Dependable 1997
What is Clinical Governance?
Where did it come from?
1989 – White paper ‘Working for Patients’ introduces Medical/Clinical Audit
Reviewing healthcare to ensure best practice is being carried out
Before 1999, NHS Trusts principal statutory responsibilities:
proper financial management ; acceptable level of patient safety; quality of care was responsibility of each clinical group
After 1999, NHS Trusts principal statutory responsibilities include quality of care
Clinical Governance
1990 – Bristol Royal Infirmary – Kennedy report 2001
Concerns raised about high mortality rates raised and ignored over 5 year period
1991 - Beverley Allitt - Clothier Report 1994
Child serial killer convicted of 4 counts of murder and 3 counts of attempted murder
1971 - 1998 - Harold Shipman – Shipman Inquiry 2005
British GP serial killer convicted of 15 counts of murder….suspected > 200!
2005 -2009 - Mid Staffs - Francis Report 2013
Poor care and high mortality rates
High profile cases adding to
Clinical Governance
7 pillars built on 5 foundation
stones
based on patient/carer
partnership
encompasses all staff groups
Very wordy!!!!
Domains of Clinical Governance
Why do we do it? Risk Management
What goes wrong? (litigation cost approx. £2bn per year)
Minimise risk to patients, staff and organisations
Openness & Honesty – Duty of Candour (Francis report)
Honesty with patient and carers when things go wrong
Willingness to learn from mistakes and change processes where necessary
Safe Practice
Feedback and Results
Complaints; PALS (patients see things that we don’t)
CPD and Research
Good quality care should come from evidenced based practice
NICE is responsible for providing national guidance
Knowledge and skills to safely care for patients
Qualified to carry out a role
Approved to carry out a role
Mandatory training – Trust wide
Ever increasing requirements
Mandatory training – Local
Focused to your own department
Non-mandatory training
Focused on your own role
Appropriate - Education & Training
Clinical Governance
Personal and peer-review audit
Images and reports
Images, reports and double scanning (perfect world)
Clinical Audit
Why is it important?
Ensure clinical standards are met (and maintained)
Ensure excellent care is delivered
Ensure systems in place for continuous improvement
Why undertake audit of your
practice?
For the patient
Make sure patients receive the best possible care
Provide patients with confidence in the service you provide
For you
Professional development – identify learning needs
Provide you with the confidence that you are doing a good job
For the organisation
NHSLA (now NHS Resolution) / CQC/ Commissioning/Quality Account requirements
Improve efficiency
Governance The use of ultrasound is becoming more and more widespread
Various professions and professional groups
Ultrasound equipment is cheap and not governed under IRR’99 [EU
law] & IR(ME)R 2000 [UK law]
National Ultrasound Steering Group
Recommendations: Recording of data; equipment evaluation and
procurement; professional clinical standards; audit
A local governance board should be in place
Oversee procurement, maintenance, replacement, maintaining
standards, training and audit
Protocols and Policies
Advanced / Consultant Clinical Practice
4 Tier Structure
The bottom line….
Work within agreed protocols/framework
Have the minimum required initial training…. Followed by continuous CPD
Subject to regular audit and review
Examples of advanced and consultant ultrasound roles
Full independent reporting; interventional procedures; CEUS;
Elastography
Key elements of a protocol
Background and title
Education and training
Scope of practice
Procedure(s) for performing or reporting examinations
Report structure
Clinical audit
CPD requirements
Verification – dates / people / approval process
References
Nightingale J, Developing protocols for advanced and consultant
practice, Radiography 2008: 14, e55-e60
Common errors in protocol design
Type of error Potential consequence
Too long Boring, not read
Too short insufficient guidance
Too prescriptive / restrictive dangerous for experienced practitioners / work outside protocol
Too loose no guidance, dangerous for inexperienced practitioners
Not evidence based / no refs won’t stand up to medico-legal scrutiny
Not properly verified / reviewed / archived
Ditto, and may not have employer cover
Do you have an existing protocol?
YES NO
Is it still relevant and current? Do you have a local hospital
template to follow?
Does it give sufficient guidance to
protect you (and your patients)?
Do you have a similar protocol in
your department that you can
review?
Is it properly verified? Do you have other hospital
protocols that you can review
MUST review and if necessary
update the protocol (with relevant
colleagues) by the end of your
module
MUST create a draft protocol by
end of the module, and have this
fully approved and verified prior to
independent / autonomous
practice
Protocols – Summary
All levels of clinical specialist ultrasound practice requires suitable
protocols and documentation
Allows for non-medical professionals to work within a safe and
effective framework
Regular review and ensuring protocol is fit for purpose
Ergonomics
Occupational injury related to ultrasound practice is increasing due
to greater workloads (more demand and shortages in staffing),
obesity in the general population, poorly designed ultrasound rooms
Repetitive and awkward movements also play a large part
Poor postural alignment during scanning
What can we do?
Ergonomics
Better awareness of scanning positions
Mixed lists
Essential for the teaching of ergonomics from the beginning of
ultrasound training
Break/catch-up slots built into lists
Regular risk assessments
Alexander Technique
Ergonomics
Things you can do
Bed height
Chair height
Patient position
Ultrasound is the most mobile of all radiological modalities
Use it as such!!
Ergonomics – Summary
Be more aware of our scanning techniques
Ensure adequate breaks and suitable lists
Professional bodies should help lead the fight in tackling these issues
Lobby the manufacturers and highlight their responsibility
to the future of the ultrasound profession!!
Health, Safety & Good Practice
Industry standards for the prevention of WRMSKD in sonography
SCoR 2006
Control Measures
Equipment; Administrative & Professional
Equipment (US Systems; Control Panel; Monitor; Transducers; Chair;
Table; Accessories)
Administrative (Education & Training; Workload & Scheduling;
Examination Area)
Professional (Best Practice)
Health, Safety & Good Practice
Chaperones
When conducting an intimate examination, the ultrasound practitioner
should:
act with propriety and in a courteous and professional manner;
communicate sensitively and politely using professional terminology,
use a chaperone when appropriate;
respect the patient’s rights to dignity and privacy,
comply with departmental schemes of work and protocols.
Health, Safety & Good Practice
The examination
Time needs to be allowed for room preparation,
assessing the ultrasound request,
introductions, explanations, obtaining consent and assisting the patient when necessary on to and off the examination couch.
Post- procedure
time is required to discuss the findings with the patient,
write the report,
archive the images and attend to the after-care of the patient, including making arrangements for further appointments and/or further investigations.
Equipment will also need cleaning and disinfecting as required post examination.
Transducer Cleaning
Recommendations
Barrier must be used
Remove the transducer cover
Clean the transducer
Transducer disinfection
High-level disinfection
MHRA alert (fatality due to infection)
Transducer Cleaning
Transducer Cleaning
Health & Saferty Executive Guidance (Ireland) 2017
https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/decontamination/ultrasound-probe-decontamination-guidance-feb-17.pdf
European Society of Radiology 2016
Infection prevention and US probe decontamination practices in Europe (2016) Insights Imaging, 7; 841-847
WFUMB 2017
Guidelines for cleaning endocavity transducers between patients
Abramowicz et al (2017) US in Med & Biol. 43 (5) 1076-1079
Selection of References
Nightingale J (2008) Developing protocols for advanced and consultant practice. Radiography, 14, e55-e60 doi:10.1016/j.radi.2008.04.001
NHS Modernisation agency, NICE. Step by step guide to developing clinical protocols. 2002. Search
at: http://www.institute.nhs.uk
Owen A, Hogg P and Nightingale J (2004), A critical analysis of a locally agreed protocol for clinical practice, Radiography, 10(2):139-144
Paterson AM, Price RC, Thomas A, Nuttall L. Reporting by radiographers: a policy and practice guide.
Radiography 2004;10:205e12.
Gibbs, V & Young, P. (2008) Work related musculoskeletal disorders in sonography and the Alexander
Technique, Ultrasound, 16 (4)
Martin, A Clinical Governance and Advanced Practice – Bolton
Bradshaw, A (2014) Be in balance: A simple introduction to the Alexander Technique.
Any Question?
THANKS FOR LISTENING
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