Tools for Patient Safety Interventions

In this document we have attempted to provide a list of tools that have been developed with the specific aim of improving patient safety. Where possible, links to these resources are provided.

This is not a definitive list and the TAPS team would welcome suggestions from you for additional resources to include in this section.

Contents

Organisational / clinical unit focus

Clinical / individual patient focus

Communication interventions and approaches

Process of care interventions

Technical interventions

Investigative interventions (incident analysis and detection)

Human Factors Design

ORGANISATIONAL / CLINICAL UNIT FOCUS

Patient safety walkrounds ™
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A tool designed by the Patient Safety First campaign led by the NPSA (National Patient Safety Agency) aimed at breaking down the barriers between management and clinical staff. Senior managers and patient safety leads take part in a planned tour of a particular area (Operating theatres, paediatric department etc) to talk face to face with frontline staff and identify good practice which could be disseminated as well as identifying areas which could be improved. They are aimed at providing an open patient safety culture within an organisation and are valuable at proving to front line staff that they are being ‘listened to’ by the senior managers.

Patient safety dashboard
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A way to visually present critical data measures in summary form so that the organisation can make quick and effective decisions. They allow organizations to work together towards the same measurable goals and can easily identify areas in which the organization is performing well and the areas in which performance could be improved. Can be applied to a wealth of different areas eg central line infections, number of cardiac arrest calls, employee satisfaction etc.

MaPSaF (Manchester Patient Safety Framework)
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A self-reflective framework which aims to help organisations assess progress in developing a safety culture. By using the tool teams are able to identify their own strengths and weaknesses hence assisting them in making patient safety a central focus within the organisation. The tool has been adapted for use in a number of setting including acute, mental health and primary care trusts.

ARHQ patient safety surveys
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The US Governmental organisation, AHRQ (Agency for Healthcare Research and Quality) have sponsored the development of patient safety culture assessment tools for healthcare organisations. The website contains a link which takes you to a survey which asks questions about the culture of patient safety in the organisation, supervisor’s attitudes to patient safety issues, communication within the healthcare team/organisation and patient safety reporting. It is an excellent resource for looking at the ‘bigger picture’ of patient safety culture within an organisation, and junior doctors could easily hand out this survey to colleagues in order to get an idea of areas of potential improvement within the organisation.

Clinical/individual patient focussed

MEWS (Modified Early Warning Score)
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A scoring system (others are available) for identifying the deteriorating patient. Nursing and/or medical staff are able to use a number of physiological parameters (heart rate, blood pressure, respiratory rate etc) to calculate a score. Once a certain score has been reached, a protocol dictates that this should be communicated to the appropriate clinician (eg critical care outreach, SHO on call etc). These tools have been shown to allow better identification of deteriorating patients and can lead to improved outcomes, however they should be used in tandem with clinical acumen and not as a sole predictor of illness.

SBAR (from the Institute of Healthcare Improvement)
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This is the Situation – Background – Assessment – Recommendation technique designed to facilitate communication between members of a multiprofessional team about a patients condition. Situation = Identify yourself and where you are calling from, identify patient by name and reason for admission, Describe reason for phone call. Background = Patients presenting complaint, past medical history and diagnosis. Assessment = Vital signs, MEWS score, clinical impression, severity of illness and any additional concerns. Recommendation = What is required, how urgent and the action needed. Suggest action to be taken, Clarify what action you expect to be taken.

Communication interventions and approaches

Handover tools
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Various templates have been produced (eg Royal College of Physicians) in order to facilitate effective and timely handover. Guidelines are also available to aid organizations setting up a new handover system. Poor handover has repeatedly been implicated as a causative factor in adverse incidents and improvement in handover has been advocated by a number of agencies. A structured evidence-based literature review on the effectiveness of improvement interventions in clinical handover published in 2008 and undertaken by the University of Tasmania eHealth Services Research Group is available to download here. A useful paper evaluating an electronic handover tool is available at http://www.mja.com.au. An excellent document published in 2004 by the BMA in association with the NPSA and the NHS modernization agency provides best practice guidance for effective medical handover (download here)

WHO Surgical checklist
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Aims to improve peri and intra-operative surgical safety as part of the Safe Surgery Saves Lives Challenge by ensuring adherence to proven standards of care.

Crew-resource management
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The application of teamwork training principles, originally developed in the aviation industry, to a variety of healthcare settings. This tool emphasizes the role of human factors in error (eg tiredness, perceptual errors). There are several key concepts:

  • To minimize potential error by training each team member to respond appropriately in acute situations
  • To develop effective communication skills and encourage a more cohesive team environment
  • Create an atmosphere where all team members are comfortable to speak up
  • To cross check each others actions
  • To offer assistance when required
  • To address errors in a non-judgmental fashion
  • To ensure thorough debriefing of adverse events and provide constructive feedback

Process of care interventions 

Clinical Pharmacist Consultation Services
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E.g. warfarin clinic. Monitoring drug therapy in a select patient population. Some services include pharmacokinetic consultation to monitor serum drug levels to ensure adequate dosing.

Care bundles
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Eg severe sepsis, central line, STEMI, Neck of femur fracture.  Developed to help healthcare organisations deliver safer care to patients undergoing predefined treatment with well recognised risks. Give uniformity to treatment without taking away the autonomy of the clinician. A small, simple set of evidence based practices that have been proven to improve outcomes when used consistently and reliably.

Medicines reconciliation
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Guidance produced by NICE and the NPSA.  Guidelines to ensure that medications prescribed on admission correspond to those that the patient was taking before admission. It is recommended that all units that admit in-patients have policies in place for medicines reconciliation including Mental Health Trusts. Organisations are advised that pharmacists should be involved in medicines reconciliation as soon as possible after the patient is admitted, to clearly define the role of each healthcare professional in the medicines reconciliation process and to ensure that there are pre-determined methods outlined to obtain information about medication in patients with communication difficulties.

Framework for double checking
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Eg Medications, blood products, controlled drugs

Technical interventions

Barcoding
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For example; blood products, medications from pharmacy, medical notes, patient ID bands Barcodes are already in use extensively with in the NHS today but their scope for increasing safety in the future is vast.

Clinical Decision Support
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Using interactive computer programs as decision making tools eg GP computer systems can be programmed to flag up when there are potential drug interactions on a prescription.

Simulation (as a form of safety training)
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Either using scenarios (e.g. ALS, ATLS courses, major incident mock-ups) or by using models (e.g. Laparoscopic training for surgeons, central line training using mannequins).

Investigative interventions

Root Cause Analysis
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A commonly used technique which can be used by organisations to try to break down the different steps that occurred prior to an adverse event or near miss. By looking at each step individually the root cause (or causes) can be identified and the organisation can reflect on ways to improve the system so that the error does not recur. The NPSA have produced an excellent root cause analysis e-learning toolkit

IHI Global Trigger Tool for Measuring Adverse Events (UK Version)
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This is a tool designed by the US Institute for Healthcare improvement which uses pre-designed data collection toolkits to retrospectively identify adverse events in order identify harm. This tool has been revised for UK healthcare systems. The tool was designed to allow organizations to gain a real understanding of the number of adverse incidents as it is thought that only 10-20% of incidents are reported using the classical reporting systems. Triggers are used (e.g. cardiac arrest, INR > 5, readmission within 30 days, return to theatre/ITU, c.difficile etc) which prompt the reviewer to look more carefully at certain aspects of the patient record to establish harm caused to the patient. A systematic order for reviewing casenotes is advised and 3 reviewers are suggested, which can be nurses, (at least one) doctor and allied health professionals. The criteria for case note review is that the patient has been admitted for at least 24 hours and that a maximum of 20 minutes is spent on each casenote. It recommends that organizations review 50 sets of notes at the beginning of the project and complete 20 casenote reviews per month thereafter.

Human Factors Design

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Human factors analyses the interaction between the way in which an individual works and the systems with which they interact. It is a well established topic which has been greatly researched and its aim is to understand how people perform under different circumstances (for example when stressed, busy or tired). The WHO defines the concept as ‘the study of all the factors that make it easier to do the work in the right way’. Knowledge of human factors can allow organisations to design systems to make it easier for members of the multi-professional team to do their job in the right way, thus theoretically reducing error. Human factors design is a method of designing systems, the environment, tools and equipment that helps a healthcare professional to complete a task in a safer and more effective manner. . A good (non-medical) website explains the concept of human factors design in a comical fashion [ http://www.baddesigns.com/ ]. The chapter entitled ‘human factors’ in the draft of the patient safety curriculum designed by the World Heath Organisation is an excellent resource, explaining the principle in a clear, concise manner.

Acknowledgements
Thanks go to Laura Dobson (BAMMbino) and the TAPs expert panel for producing this document.