undertaking root cause analysis dr. peter woodhouse, chair, thrombosis & thromboprophylaxis...
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![Page 1: Undertaking root cause analysis Dr. Peter Woodhouse, Chair, Thrombosis & Thromboprophylaxis Committee, Norfolk & Norwich University Hospital](https://reader037.vdocuments.site/reader037/viewer/2022103112/551ba05455034675548b45e4/html5/thumbnails/1.jpg)
Undertaking root cause analysis
Dr. Peter Woodhouse,Chair, Thrombosis & Thromboprophylaxis Committee,Norfolk & Norwich University Hospital.
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•~1010 beds•~70,000 adult discharges / year•~70,000 adult day cases / year
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VTE prevention programme
•Comprehensive local clinical guidelines•Drug chart Thrombosis Risk Assessment (TRA)•Monthly audit of TRA completion, all adult wards•HAT root cause analysis
•Deaths since Jan 2009•Non-fatal since Sept 2009
•Monthly ‘HAT report’ published Trustwide•Patient information•Link Nurses•‘Click for Clots’ intranet site
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Thrombosis Risk Assessment (TRA) completion (ward audit)
37 39 42 46
7585 89 94 95 93 92 97 95 96 97
63 61 58 54
2515 11 6 5 7 8 3 5 4 3
0102030405060708090
100O
ct-0
9
Nov
-09
Dec
-09
Jan-
10
Feb-
10
Mar
-10
Apr-
10
May
-10
Jun-
10
Jul-1
0
Aug-
10
Sep-
10
Oct
-10
Nov
-10
Dec
-10
% TRA not completed
TRA completed
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HAT Root Cause Analysis (RCA)Why do it?
• To find out why it happened• To find out if it could have been avoided• To find lessons to be learnt
• To motivate / engage fellow clinicians– We had seen it work before for C.Difficile
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What’s a HAT?
• Hospital Acquired (or Associated) Thrombosis– DVT or PE during hospital admission
• What about those who probably had DVT / PE on admission but not initially suspected?
– DVT or PE within 90 days of discharge• We initially chose ‘within 30 days’ (until April 2010)
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How did we find the HATs?
• Non-fatal– Inpatient anticoagulation (warfarin dosing) service– DVT clinic
• Fatal– Pathology Liaison & Bereavement Nurse
• Death certificates• PM reports (including Coroner’s)
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Root Cause Analysis
•Case reviewed and sections 1 to 3 completed by member(s) of T&T team. •Partially completed form sent to Consultant responsible for index admission to complete Section 4•Completed RCA form returned to T&T team, data collated and entered onto database.•Common themes identified•Summary results contribute to monthly HAT report
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Root Cause Analysis
•Case reviewed and sections 1 to 3 completed by member(s) of T&T team. •Partially completed form sent to Consultant responsible for index admission to complete Section 4•Completed RCA form returned to T&T team, data collated and entered onto database.•Common themes identified•Summary results contribute to monthly HAT report
![Page 10: Undertaking root cause analysis Dr. Peter Woodhouse, Chair, Thrombosis & Thromboprophylaxis Committee, Norfolk & Norwich University Hospital](https://reader037.vdocuments.site/reader037/viewer/2022103112/551ba05455034675548b45e4/html5/thumbnails/10.jpg)
Root Cause Analysis
•Case reviewed and sections 1 to 3 completed by member(s) of T&T team. •Partially completed form sent to Consultant responsible for index admission to complete Section 4•Completed RCA form returned to T&T team, data collated and entered onto database.•Common themes identified•Summary results contribute to monthly HAT report
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• 162 HATs per annum (2010)– 125 non-fatal (62 PE / 63 DVT)– 37 fatal (31 PE / 6 DVT)
• ~ 2 / 1000 inpatient episodes• Location of VTE diagnosis
– 46% index admission– 36% readmission– 18% outpatient / community
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HAT deaths 2009-2010
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HAT Deaths <30 days post-discharge
• 2009–Total 36
• 30 PE• 6 DVT
• 2010–Total 31
• 31 PE• 0 DVT
• Further 6 PEs, 30-90 days
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Non-fatal HAT 2009-2010
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HAT by age & gender
Deaths (n=73)
• Mean age 78 years
• 51% male• 49% female
• 86% emergency• 14% elective
Non-fatal (n=165)
• Mean age 66 years
• 45% male• 55% female
• 63% emergency• 37% elective
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HAT by Specialty
Deaths (n=73) Non-fatal (n=165)
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HAT by Predominant diagnosis
Deaths (n=73) Non-fatal (n=165)
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Risk assessment and prophylaxis in HAT cases
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Compliance with NICE CG92
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Root cause of HAT
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Problems identified and tackled along the way
• Failure to risk assess– Education campaign, drug chart risk assessment
• Delay in first dose of LMWH– ‘Thromboprophylaxis round’ in the evening on orthopaedic
wards
• Unexplained gaps in LMWH prophylaxis– Targeted audit
• Inappropriately Low-dose LMWH– Tinzaparin 3500 units removed from stock– Education re. correct dosing in renal impairment
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Problems identified and tackled along the way
• Delay in diagnosis and treatment of VTE– Education
• Failure to prescribe according to the risk assessment– Audit and feedback, re-design drug chart TRA
• Some VTE events seem to be unpreventable– Maintain morale and commitment to VTE prevention
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Using the results of RCA
Hospital Associated Thrombosis (HAT) Monthly Report
December 2010
Liz Lorie, Specialist Nurse,Nicola Korn, Specialist PharmacistHamish Lyall, HaematologistJennie Wimperis, HaematologistPeter Woodhouse, Chair, T&T Committee
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Trust intranet site•Links to local and national guidelines•‘HAT reports’ / audit reports•Treatment protocols•Patient information•Adverse incident reporting
•‘Blog for bleeding’•Feedback to anticoagulation service and T&T team
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Resources required•Specialist Pharmacist•Specialist Nurse(s)•Pathology Liaison Nurse•Two Haematologists•Geriatrician•Head of Pharmacy•IT Web Specialist•Supportive management
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Any questions?