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The Scottish Patient Safety Programme. NHS FIFE LEADERSHIP WORKSTREAM. Moving the Dot! Cardiac Arrest Review. Cardiac Arrest review of 20 pts requested by CEO to review the quality of clinical processes in place in the 72hours prior to cardiac arrest

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the scottish patient safety programme

The Scottish Patient Safety Programme


moving the dot cardiac arrest review
Moving the Dot! Cardiac Arrest Review
  • Cardiac Arrest review of 20 pts requested by CEO to review the quality of clinical processes in place in the 72hours prior to cardiac arrest
  • Look specifically at FEWS (Fife early warning scores) within the 72 hours.
  • To consider whether a DNACPR should have been in place.
  • Incorrect addition of scores, leading to underassessment of severity
  • Oxygen saturation scores almost always zero due to concurrent oxygen therapy even in patients with severe respiratory morbidity
  • Neurological observations poorly performed / understood leading to falsely low scoring of severity
  • Need improved quality of data collection and addition
  • FEWS data fidelity needs to be improved
  • Oxygen saturations inneffective at recognising respiratory morbidity
  • Neurology scoring poor
  • Majority of clinical episodes satisfactory / good
  • Some areas need feedback
  • Communication with family an issue
  • DNACPR forms not filled out even when deteriorating trend is obvious
building capacity
Building Capacity
  • Rolling SPSP Programme Overview to:
  • Nursing students (Campus and clinical placement)
  • Medical Students
  • FY1/FY2 Drs
  • Consultants
the scottish patient safety programme6

The Scottish Patient Safety Programme



Med Directorate carried out Box 4 Mortality Review Feb 2010

  • 70 notes reviewed
  • 21 areas where harm possibly occurred
  • Follow up meeting planned to learn from the outcome of the review
  • Strategy to address the issues


  • FEWS high and not acted upon or a low score considered in isolation of deteriorating condition
  • Blood results out of range/untimely response
  • HAI
  • Readmission within 30 days
  • DVT / PE Episode

PDSA cycles regarding the production of NHS Fife’s Early Warning Score Algorithm culminated July 2010. Algorithm printed on reverse of Fife Early Warning Score charts.


PVC Insertion label – introduced March 2010


Insertion date …….…………………….…

Insertion time ……………………………

Dressing dated & timed …………………

Position of cannula ……………………… Reason for insertion

Inserted by ……………………….………


Print clearly

PVC Daily Check label – introduced March 2010

Peripheral Vascular Catheter Care Bundle HPS


Date: / / Time:

Cannula site:

Cannula gauge / colour:

Still in use / required Y N

Absence of inflammation / extravasation Y N

Dressing intact and dated & timed Y N

Inserted for less than 72 hours Y N

Hand hygiene before & after all PVC bundle

checks Y N

Please circle PVC removed PVC left in situ

Reason for removal:

help please
  • Electronic reporting system
the scottish patient safety programme16

The Scottish Patient Safety Programme







Peri-operative Trajectory

Awareness raising/slippage time

Implementing (Measuring & Reporting)

Sustaining (Over 95% for 3 months)





‘Chitter Chatter’

Preoperative Warming Campaign

After introducing the ‘Chitter Chatter Preoperative Warming Campaign’ a significant improvement can be seen in the Orthopaedic Theatre.


Surgical Outpatient Department spreading patient safety

  • briefings to all specialities
  • Patient safety briefings are being introduced to ERCP
  • procedures (Endoscopy Department)
  • Patient safety briefings are being introduced to Radiology
  • procedures (Radiology Department)

‘What song titles best describes the last 3 years of participating in the Scottish Patient Safety Programme……………’


2008 – ‘with a little help from our friends’

  • 2009 – ‘come on baby light my fire’
  • 2010 - ‘we’re on our way’
  • 2011 – ‘Shout’
the scottish patient safety programme25

The Scottish Patient Safety Programme

NHS Fife – Medicines Management Workstream


NHS Fife Medicines Management Team

Donald Coxon – Chief Pharmacist & Team Leader

Sandy Kopyto – Anticoagulation Lead

Bruce Wilkie – Medicines Reconciliation Lead

Paul Smith – Workstream Coordinator/Facilitator

Valuable support is provided by a variety of medical staff, nursing staff, pharmacists and others including: - Pauline Cumming (NHS Fife Risk Manager), Dr Laura Clark (Acute Consultant Physician), Dr Lynn Miller (Consultant Cardiologist), Dr Krishnan Swaminathan (Diabetes Consultant), Dr Vera Cvoro (Care of the Elderly Consultant), Euan Reid (Senior Clinical Pharmacist), Sharon Robertson (Diabetes Specialist Nurse), Tessa Kidd (Diabetes Specialist Nurse), Caroline Craig (Diabetes Specialist Nurse), Rhona Wallace (Practice Development Facilitator), Lorna Bellingham (Senior Charge Nurse), Lorraine McComiskie (Preassessment Nurse), David Binyon (Development Pharmacist), Cath Stewart (Nurse Practitioner), Hazel York (Diabetes Specialist Nurse), Julie O’Neill (CHP Risk Manager), Alan Timmins (Principal Pharmacist), Dr Stella Clark (Medical Director PCD)

improving warfarin safety
Improving Warfarin Safety
  • In 2008, Multi disciplinary team carried out a Failure Modes & Effects Analysis (FMEA)
  • Developed action plan to address highest risks identified around patient education, communication with Primary Care and Prescribing.
  • Key improvements included enhancements to patient education/counselling sheet, discharge process incl. mandatory INR follow up appointment with GP and prescribing protocols with more varied loading regimes
  • Process supported by regular review of action plan implementation and monthly case note reviews
  • The case note review process has identified links with high INR and co-prescribing of antibiotics– to be highlighted in forthcoming protocol
  • Measurement is constantly being refined – now measure number of patients with INR over 6 per hospital, per month rather than overall percentage of INRs over 6 as many patients have multiple draws
number of patien ts with inr over 6 at victoria hospital kirkcaldy
Number of patients with INR over 6 at Victoria Hospital, Kirkcaldy

This measure was introduced as it became apparent that the previous measure relating to percentage of INRs over 6 per month was failing to show improvement as it contained multiple draws for several patients

number of patients with inr over 6 at queen margaret hospital dunfermline
Number of patients with INR over 6 at Queen Margaret Hospital, Dunfermline

Differences were noted between the 2 main hospitals. These have been linked to the variance in Pharmacy support and compliance with patient education

case note reviews antibiotic interactions with warfarin
Case Note Reviews – Antibiotic interactions with Warfarin

Monthly case note reviews for a sample of 20 patients/month admitted with INR over 6, continue to identify antibiotic triggers with a high percentage of patients. We are now starting to identify where these have been prescribed. The issue will be highlighted in the forthcoming anticoagulation protocol

warfarin safety red ucing the fmea score
Warfarin Safety – Reducing the FMEA score

The team meets regularly to review progress and identify new risks. We have been able to reduce the FMEA RPN score from 1523 to 864. We are however still finding pockets of non compliance and areas we missed!

improving insulin safety
Improving Insulin Safety
  • In September 2009, multi disciplinary team carried out a FMEA. The group has subsequently met 6 times and communication has been particularly highlighted to ensure that everyone who needs to know or has an interest is involved. The Diabetes MCN is regularly updated
  • The FMEA document is now in version 2.2 and the action plan in version 6. The highest risks identified were around prescribing information, communication and referral pathway information as well as staff education
  • Key improvements included enhancements to :- IV and subcutaneous insulin prescribing charts, hypoglycaemia and hyperkalaemia protocols and a Fife-wide review of the Diabetes Handbook
  • Process supported by regular review of action plan implementation and audits
  • Identifying suitable measures has been difficult – have looked at insulin prescribing audit to identify ‘error base rate’ and also at issue of hypo antidote products from Pharmacy to indicate better management and control.
improving insulin safety measurement
Improving Insulin Safety - Measurement

We have tried to develop a measure to identify a reduction in our hypoglycaemia rate by asking pharmacy to provide data on the issue of glucose gel and glucose 50% injection products as a percentage of all glucose products but hasn’t really been successful…now looking at a prescribing error rate based on PSF insulin bundle…

other fmeas
Other FMEAs?
  • The process has worked very well for us in looking at high risk medications.
  • 2 more are planned long term
    • Chemotherapy
    • Opiates
implementing medicines reconciliation
Implementing Medicines Reconciliation
  • Our biggest challenge…
  • Only implemented successfully in one ward, but analysis of discharge letters from this area has shown them to be of high quality due to reconciliation that has taken place on admission.
  • Acute admissions units still not compliant despite continuous efforts to identify a process that works
  • Now are routinely getting ECS printouts which are being added to patients’ notes during clerk in
medicines reconciliation why hasn t it worked
Medicines Reconciliation – why hasn’t it worked?
  • We have asked this question many times…
  • Not enough time to do properly during admissions process, lack of understanding/clarity of definition, lack of standardised admissions processes and documentation, doctors rotate frequently, ECS issues (consent, printouts), pharmacy support not always available, no patient or relative education, not seen as critical, lack of an easy IT solution, difficult to find evidence e.g. incident data to prove level of potential harm, no ‘one-size-fits-all’ solution
medicines reconciliation what is going well
Medicines Reconciliation – what is going well
  • We have a thoroughly tested medicines reconciliation form that works and captures all essential information.
  • Ward clerks are now printing off ECS for all patients in medical acute admissions units where they are not accompanied by a GP letter
  • We are concentrating our efforts on utilising the ECS print out as the basis for medicines reconciliation but it is not designed for that purpose; not enough doctors are signed on and we haven’t managed to achieve sufficient awareness that this is a critical admissions component
medicines reconciliation measurement
Medicines Reconciliation measurement

Compliance is very high in the one area to which we have introduced this process. We have recently held a review with Preassessment, nursing and Practice Development staff on the ward. The process is popular with doctors and has been seen to enhance quality of discharge letters. Case Note reviews and audits are planned to verify this

nhs fife medicines management workstream what is our plan
NHS Fife Medicines Management workstream – What is our plan?

Next steps in Medicines Management

  • Develop the medicines reconciliation process using ECS printouts and identify a process which doctors, nurses and pharmacists can live with and which makes a difference to patients! Continue testing and spreading of insulin IV and Subcutaneous prescribing guidance and complete the review of the Diabetes Handbook by December 2010
  • Tidy up some loose ends with the warfarin safety work – complete the NHS Fife protocol, provide education for community hospitals, and so on
the scottish patient safety programme40

The Scottish Patient Safety Programme

NHS Fife – Critical Care Workstream

your aims and programme goals
Your Aims and Programme Goals

Mortality: 15% reduction

Adverse Events: 30% reduction

Ventilator Associated Pneumonia: 0 or 300 days between

Central Line Bloodstream Infection: 0 or 300 days between

Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range

Staph Aureus Bacteraemias: 30% reduction

Crash Calls: 30% reduction

Harm from Anti-coagulation: Reduction in INRs > 6

Surgical Site Infections: 50% reduction in population of choice

All process measures will be > 95% reliable


Scottish Patient Safety Programme:

NHS Fife Critical Care Work Stream Current Work:

Drivers and Changes

Secondary Drivers

Process Changes

Primary Drivers


Reduce complications

from ventilators

Use VAP Prevention Bundle (SIGSAG)

Provide appropriate , reliable and timely care to critically ill patients using evidence- based therapies

Reduce complications from central venous catheters

Use Central Line Insertion and Maintenance Bundle (SIGSAG)

Improved critical care outcomes .

(Reduce mortality , infections and other adverse events )

Achieve optimal glucose control

Develop Blood Glucose protocol

Prevent healthcare associated

infections and cross contamination

Use PVC bundle (HPS)

Establish reliable hand hygiene

Create a highly effective and collaborative multidisciplinary team Involve patient and family in care planning

Reliable planning, communication and collaboration of multi disciplinary team

Establish multidisciplinary ward rounds and daily goal planning

achieve optimal glucose control previous practice
Achieve Optimal Glucose ControlPrevious Practice
  • No standard practice for recording BM
  • No standardised blood glucose at which insulin was commenced
  • Always used the NHS Fife insulin sliding scale
  • Always ensured that patient was on NG feed but not always ensured IV Dextrose was in place if no feed in place.
baseline audit is there a problem
Baseline Audit – is there a problem
  • Not bad control…but room for improvement
  • Good that nurses exercise caution
  • Sliding scale almost always needed revised in critically ill patients - Inotropes/Vasopressors/Steroids/Feed all increase BM
  • Standardise how often BM are taken
  • Insulin should be started earlier





















Secondary Drivers:Achieve Optimal Glucose Control


Weekly audit

Total number of BG within past 24 hours within range / Total number of BG recorded

Change 4: Joanna Briggs

Audit Tool

Change 3 :Education and changes in practice

Change 2: Testing and implementation of protocol

Change 1: Develop Blood Glucose Protocol


START when a single BG > 9 or two consecutive BGs between 8-9

BG > 8start insulin 1unit/hour

BG > 12start insulin 2units/hour


Stop insulin

Give 20 mls 50%dextrose

BG 6.1-8



BG every 30 min till>4

Measure BG hourly

BG 2 hourly if insulin dose stable for3hrs

BG 4.1-6

Halve insulin

Measure hourly

Follow table till target achieved


Follow table till target achieved

Blood Glucose Change In Insulin

6-8 No change

8.1-12.0 Increase by 0.5 unit

> 12.1 Increase by 1 units

If difference between current and previous BG reading < 0.5 mmol wait an hour to increase insulin

Blood Glucose Protocol

Flow Chart

keys to success
Keys to Success
  • Develop Blood Glucose Protocol – allow for more individualised approach for critically ill patients
  • Test and test again (PDSA)– initially tried to implement without enough testing – poor results and learned from mistakes
  • Needs – education and changes in practice
  • A key factor in enabling Critical Care to move forward with measuring compliance with Blood Glucose was to use the Joann Briggs Institute ( JBI) Audit Tool – involved clinical staff and weekly display of compliance

Difficulties Along the Way

  • Increased workload for nursing staff
  • Lack of cooperation with some medical staff
  • Change over to using Glucose as our main diluent for IV additives
  • Occasional use hydrocortisone had effect on BG
  • Didn’t work for everyone.

ICU , Queen Margaret Hospital

Blood Glucose

Target 80% between 4.4 – 10mmol/L


Protocol introduced

June 2009

August 09 BM parameters

changed to 4.4-10.0mmols

major challenges and barriers
Major Challenges and Barriers

Increasing demands from other local and national initiatives / changes

Spread to the HDU’s – new driver diagram and measurement plan - Help with this