b4 sue fuller blamey - transitioning patients between bc cancer agency & vancouver - acute...
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Transitioning Patients Between
BC Cancer Agency & Vancouver – Acute Services
Quality Forum
February 28, 2013
Sue Fuller BlameyDarren Kopetsky
Lorraine Blackburn
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Case for Change
Patient Safety Event with a patient transferred from Vancouver General Hospital (VGH) to BC Cancer Agency for an out-patient Radiation Therapy appointment
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Collaboration between BC Cancer Agency and Vancouver General Hospital
•Met with leaders, educators, physicians & front- line staff from both Hospitals•Reviewed transfer process between organizations
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Review of Transition Processes
• Realized that the process was really complex with many possible ways for the process to fail•Conducted a Failure Modes Effects Analysis (FMEA) to identify defective process steps and mistake-proof the process•Listed the top 12 ways that the process could fail
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Transfer Failure Modes
1. Lack of Communication about patient needs
2. Lack of pain management plan prior to transfer
3. Nurse unaware of care plan4. No medication with transfer5. Unclear physician’s orders6. No 7 rights of medication
administration
7. No after-hours policy for retrieving medication at BCCA8. Nurse uneducated about BCCA RT protocol9. No policy for VCH nurse to give medications at BCCA10. VCH nurse unaware of BCCA procedure for radiation therapy11. No communication back to sending hospital from BCCA12. No physician follow-up post- procedure
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Reviewed Reasons for Failure Modes
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Failure Modes Analysis Worksheet
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Analysis of Failure Modes
•Listing the root causes•Scoring severity and probability of recurrence•Identifying solutions to mistake-proof the root causes/failures
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Recommendations/Solutions
1. Staff at VGH and BCCA need to communicate verbally and in writing prior to patient transfer
2. VGH staff to contact physician prior to transfer if patient condition changes
3. VGH staff education re: RadiationTherapy procedure
4. Discussion at BCCA MAC re: appropriate use of verbal orders
5. Patient requires pain management plan prior to transfer
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Created Checklists for BCCA and Vancouver – Acute Services Hospitals
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Created Checklists for BCCA and Vancouver – Acute Services Hospitals
•
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Clinical Practice Document Vancouver – Acute Services
07/21/11
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Recommendations/Solutions
6. Create intra-facility policy on ability for VGH nurses to give medications at BCCA & after- hours medication procurement at BCCA
7. Education re: 7 rights of medication administration
8. Protocols for giving medication after-hours at BCCA
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Recommendations/Solutions
9. BCCA Communication back to sending facilities10. PHSA Handovers Framework
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Further Work on Handovers & Transitions in Both Organizations
PHSA: Handovers and Transitions FrameworkAddresses three types of hand-offs (Internal, External, Intra- agency/health authority).•Each PHSA agency or service must include in their processes and procedures the following core elements:
a)Standard mechanism of transferb)Patient/Caregiver involvementc)Interactive communicationd)Comprehensive informatione)Review of previous historyf)Documentationg)Ensure minimal interruptions
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Further Work on Handovers & Transitions in Both Organizations
Vancouver – Acute Services
•Clinical Practice Document on Transfer of Patients for Tests/Procedures: Patient Accompaniment
• expands use of checklist beyond BCCA
• identifies when accompaniment is required, and what to consider when using clinical judgment to establish requirements in other scenarios.
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Reporting, Measuring & Evaluation
Number of BCCA Transition Events
0
5
10
15
20
25
30
Nov Jan
Mar
may Jul
Sep Nov Jan
Mar
May Jul
Sep Nov
Month
# of
eve
nts
# of transition events
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Next Steps – Roll out to other Health Authorities
•Transfer Checklist rolled out to Fraser Health – Abbotsford & Surrey•Plans to invite all other Health Authorities to roll out process
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Key Learnings
• Need to collaborate with key stakeholders to get to the bottom of all root causes of the failures in a process
• Need to understand each other’s process in order to make adjustments to prevent errors
• Need to regularly communicate even after project implementation
• Re-implementation of education and procedures is a constant issue
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Thank you to Participants in this Process
Dr. James MorrisLise BelangerDr. Peter LimDr. Ryan CarlsonBrendan TomkinsFrankie Goodwin
Janice DirksenKaren JanesLorraine BlackburnDarren KopetskySue Fuller Blamey
07/21/11
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Questions?