DEVELOPMENT OF A PATIENT SAFETY INDEX FOR HAEMODIALYSIS K White - - PowerPoint PPT Presentation

KELLY WHITE BSc

DEVELOPMENT OF A PATIENT SAFETY INDEX FOR HAEMODIALYSIS

K White BSc, Prof M W Taal, Dr R J Fluck, C Rhodes RGN, Dr L J Chesterton, C A Fielding RGN

INTRODUCTION

• Haemodialysis is a widely used therapy that is associated

with multiple risks for patients such as;

• Adverse reactions
• Problems with vascular access
• Incidents related to extracorporeal circuit
• Errors in treatment performance
• Monitoring can improve patient experience

BACKGROUND

• Haemodialysis trigger tool

Allows regular monitoring of adverse incidents Outlines triggers specific to haemodialysis Identifies areas of recurrent harm

Category E: Category F: Category G: Category H: Category I: Code Trigger Trigger ? (1 ) Severity (E-I) Brief Description G1 Vomiting G2 Fever >38C G3 Symptomatic hypotension G4 Loss of consciousness G5 Unplanned admission post HD G6 Chest pain G7 Cardiac arrest G8 Cardiac arrhythmia G9 Emergency medical assessment G10 Blood transfusion G11 Oxygen therapy G12 Fall pre or post HD G13 Cramps without hypotension y y d y y DERBY HOSPITALS: HAEMODIALYSIS TRIGGER TOOL GENERAL CARE MODULE VASCULAR ACCESS MODULE contributed to or resulted in permanent patient harm required intervention to sustain life contributed to the patient's death contributed to or resulted in temporary harm to the patient & required intervention contributed to or resulted in temporary harm to the patient & required initial or prolonged hospitalisation

HAEMODIALYSIS TRIGGER TOOL

• Has identified areas of

frequent harm

• Interventions used to reduce

harm risk

• Limitations

– Complex design – Time consuming – Small number of treatments can be audited

AIMS

• Develop a simplified tool
• Allow audit of more treatments
• Based on results of HTT
• Treatment areas discussed

DERBY PATIENT SAFETY INDEX FOR HAEMODIALYSIS

• PUT PICTURE OF DPSI HERE!
• Pilot performed over 1 week in April 2016
• All treatments audited
• Staff given questionnaire to complete

RESULTS

• 592 treatments audited over

6 days

• 111 adverse incidents (19%)

– Hypotension = 43 (7%) – Multiple cannulation attempts =26 (4.3%) – Reduced HD time =29 (5%) – Hypoglycaemia =10 (1.7%) – Prescription errors = 3 (0.5%) – VND = 0

QUESTIONNAIRE RESULTS

5 10 15 20 25 Q1 Q2 Q3 1 2 3 4 5

• Q1 How easy did you find the

patients safety index to use?

• Q2 How easy did you find the

index to understand?

• Q3 How easy were you able to

interpret the definitions of each category?

• Approximately how long did it take

to complete the index? – Answers ranged from 20s per patient to 2 minutes per patient

1 = DIFFICULT 5 = EASY

Easy to use

Drop down menus Straight forward

Hypotension and multiple cannulation columns

Gives auditable data

VND CATEGORY UNNECESSARY

Duplication

Different place to vital data

CONCLUSION

• Easy and simple to use
• Allows audit of potentially all treatments
• Highlights frequent harms allowing the introduction of strategies to

reduce them

• Encourages staff vigilance and focussed interventions to prevent harm

events

• Provides a rounded approach to patient safety during haemodialysis

treatment

• We hope that other dialysis providers will consider adopting the DPSI

to improve patient safety

WHAT NEXT?

• Continue with regular audits
• Integrate with current IT system
• Respond to changes in frequency of harm events
• Improve patient experience of haemodialysis

Thank you

Any Questions?

kelly.white@nhs.net