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Scottish Patient Safety Paediatric Programme – Tests & Measures. Combined Child Services, NHS Grampian. Testing & Implementing Surgical Briefing Paediatric Trigger Tool PEWS PVC Bundle Medicines Reconciliation Safety Briefing Hand Hygiene SBAR. Measuring Surgical Briefing
Combined Child Services, NHS Grampian
RACH Adverse Event Rate 2010
Team & Process
Learning so Far
Note reviews carried out 3 months later to ensure closed cases.
Change 1: Tested SBAR in HDU ward
for communication between medical and
nursing staff when telephoning. Posters
Developed to facilitate education of staff on
Change 2: Tested SBAR for transfer of
patients from HDU to other wards. This
facilitated HDU to begin their testingon
handover back to the general wards.
Change 3: HDU using SBAR to structure
nursing handover and linked with safety
briefing. Results have shown decreased
handover time and improved
Change 4: SBAR implemented on surgical
ward by Consultant as the method of
communication re patient’s status, actions,
treatment plan on the ward round. Staff
view is that process is succinct.
Change 5: NHSG Inter-hospital transfer
SBAR is being adapted and tested to fit
Change 6: SBAR used by senior nurses in
RACH as structure for formal reports.
Change 1: Adult pilot sites shared their safety briefing form and process with Child Health. V1 of form tested by SCN as part of handover in one team of medical ward. Changes made to process and form and continued testing and then implementing with one team.
Change 2:Testing then spread to other medical team.
Change 3: Implemented in medical ward on a daily basis. Learning shared with HDU.
Change 4: Begun testing in HDU 1-3-5 all and now implemented.
Change 5: Spread to other areas
Change 1: V1 of form tested with 1 doctor, then tested with 1 nurse as either professional my collect medication details. Changes made to layout.
Change 2:V2 including the introduction of insulin box tested 1,3 then required alterations highlighted
Change 3: V3 tested also extensive discussion relating to children who have no regular medicines. To complete a form or not?
Change 4: V4 created including a box to identify if the child is on no regular medicines. This is currently in use across PAU
Change 5: V5 in progress need to reintroduce continue column in the reconciliation section. To be tested by Tuesday!
Change 1: Began testing the perioperative briefing, pause and debriefing process.
Change 2:Tested posters to convey process for safety checks. Large surgical pause posters in each theatre to act as prompt for the process.
Change 3: Checklist developed to capture data on briefing, pause and debrief. Tested and implemented.
Change 4: Measuring compliance with the process from January 2010. Improvements noted in both briefing and pause compliance. Further work required on debriefing elements.
Change 5: Now working on other perioperative measures.
Next step to work on debriefing
Change 1: Document piloted and evaluated in A&E and Paediatric Assessment Unit (PAU). Found to conflict with Manchester Triage System.
Change 2: Frequent education sessions for medical and nursing staff looking at evidence base and practical uses.
Change 3: Implemented across RACH and Dr Gray’s Hospital Elgin.
Change 4: Compliance monitoring commenced in the Surgical Unit.
Change 5:Compliance monitoring now in PAU, Medical and Surgical Units.
Reason for Access
97% of inserted PVC were accessed
< 72 hrs
Length of Time Inserted
> 72 hrs
41% IV 3000
1% Pink Elastoplast Tape
Resiting of PVC