A Quality Improvement project in Temple Street Children's Hospital, undertaken by graduates of our Diploma in Leadership and Quality in Healthcare, has won a major Patient Safety Initiative Award
The project team (led by Diploma graduates Mona Baker, Professor Alf Nicholson, Dr John Fitzsimons and Dr Colin Doherty) won the award on Friday 10 May 2013 at the Biomnis Healthcare Innovation Awards for ‘Enhancing a Culture of Patient Safety by using the Paediatric Trigger Tool to Measure Harm’ undertaken as part of the Diploma in Leadership and Quality in Healthcare.
The aim of their project, which is still ongoing, is to measure harm, and identify and learn from potential adverse events. It also enhances the voluntary reporting mechanisms already established in the hospital.
The tool used by the Temple Street team is the NHS Paediatric Trigger Tool (PTT). This is a structured method of measuring harm by performing standardised reviews of randomly selected healthcare records. It is an unbiased measure of the incidence of harm, and more importantly it allows you to prioritise patient safety improvements and track change over time.
The tool defines a series of "triggers", grouped together to reflect different aspects of care (general care, surgical care, intensive care, medication and pathology). A trigger is a flag or signpost that helps reviewers find adverse events that occurred during care. For example, the use of an antidote medication suggests there may have been an overdose of medication.
The PTT team in Temple Street consists of three teams of reviewers (nursing, pharmacy and management) and two clinician supervisors, with ongoing support and leadership provided by the hospital CEO. Thirty charts are reviewed every month by the reviewers, who then meet with the clinician supervisors to discuss and analyse results.
In Temple Street, the teams of reviewers look for triggers in the healthcare records of children discharged 30 days previously. If a trigger is found, the notes are examined to find the root cause and identify if harm occurred. If harm occurred, it is graded according to an adapted version of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index. The Temple Street team defines harm simply as “something that you would not want to happen to your child as a result of healthcare”.
So far, 240 charts have been reviewed, and 22 episodes of harm have been recorded (2.2 per month). The most common category of harm is E: temporary harm to the patient that required intervention. Results are reported through the hospital’s clinical governance structures, with agreed changes implemented as required.
While the PTT started life as a Quality Improvement project, it was important to embed it in the hospital’s Patient Safety and Clinical Governance structures to keep it going. Clear leadership by the hospital CEO, Professor Alf Nicholson and John Fitzsimons, as well as the enthusiasm and dedication of the reviewers and clinical supervisors has ensured this.
Professor Alf Nicholson said, “As a group we recognised the importance of patient safety and its potential to engage staff in efforts to improve care and alter safety culture. We were aware of a method call trigger tools that allowed organisations to measure the level of harm that occurs during the course of care. There was initially a fear, shared by the hospital physicians and the study team, that the process would become one of ‘blame’ and instead of creating a culture of safety we could create a culture of blame. From the outset we assured the clinical teams that this was not a ‘big brother’ exercise, nor was it a benchmarking tool for making comparisons between paediatric teams. We now have a measure of patient harm which helps staff to discuss methods that will reduce this, with the ultimate aim of eliminating it.”
Professor Nicholson added, “We would like to acknowledge the advice and support provided by Dr Peter Lachman and Dr David Vaughan from the RCPI Diploma in Leadership and Quality in Healthcare.”
The Biomnis Healthcare Innovation Awards took place in the Clyde Court Hotel, Dublin on 10 May 2013. The Biomnis Healthcare Innovation Awards are organised by Investnet Healthcare.
Our Diploma in Leadership and Quality in Healthcare is equipping senior healthcare professionals (both clinical and management) with the expertise and tools they need to continually improve the quality of service they provide.
The Diploma is funded and supported by the Quality and Patient Safety Directorate under the direction of Dr Philip Crowley and focuses on patient safety, leadership, the measurement of harm, strategies to reduce rates of harm, and the science of quality improvement.
Participants undertake a year-long quality improvement project in the workplace, and as a direct result, we are now seeing remarkable results in individual healthcare institutions across Ireland.