Content from National Patient Safety Agency material Identifying Problems Identifying Problems Care and Service Delivery Problems (CDPs + SDPs) Concept of care and service delivery problems - Vincent and Adams (1999)

Content from National Patient Safety Agency material Gathering Information & Mapping the Incident Identifying Care & Service Delivery Problems Analysing Problems & Identifying CFs and RCs Generating Solutions & Recommendations Implementing Solutions Writing the Report Getting Started The RCA Process

Content from National Patient Safety Agency material CDP/SDPs Every point where: Something happened that shouldn’t have OR Something that should have happened, didn’t. What are Care/Service Delivery Problems (CDP/SDPs)?

Content from National Patient Safety Agency material Care Delivery Problem (CDP) i.care deviated beyond safe limits of practice and ii the deviation had a direct or indirect effect on the eventual adverse outcome for the patient Problems that arise in the process of care… …usually actions or omissions by staff Failure to monitor, observe or act Incorrect decision or action Not seeking help when necessary

Content from National Patient Safety Agency material Service Delivery Problem (SDP) Acts or omissions identified during the analysis of the incident, but not associated with direct care provision. Fail to undertake environmental risk assessment System for ensuring all new telephones have an emergency number for switchboard on them …These are generally associated with decisions, procedures and systems that are part of the whole process of service delivery.

Content from National Patient Safety Agency material Some will jump out immediately Others emerge, particularly when the clinical team involved is invited to contribute... Never assume your organisation / team is doing what you (or even they!) think they’re doing Peter Pronovost How to identify CDPs and SDPs

Content from National Patient Safety Agency material To determine CDPs and SDPs Consider holding an Multi Disciplinary Team meeting This approach is valuable to:- Clarify your ‘map’ of the incident Identify CDPs + SDPs and contributory factors Invite those involved or interested to take part and learn from the process Gain help finding workable solutions Share the report and debrief staff on the learning It can also work well therapeutically Especially where ‘perceived’ blame issues need to be worked through! (NB: Wherever reckless, malicious or criminal activity is ‘actually suspected’, these issues are transferred to other experts for action)

Content from National Patient Safety Agency material But… Tensions may be running high It may be difficult to get everyone together So… Consider seeing people in smaller groups And… Practise with a low-harm incidents first

Content from National Patient Safety Agency material RCA tools to help identify CDPs & SPDs Change analysis Nominal group technique RCA Tools

Content from National Patient Safety Agency material Change analysis – the process 1.Describe the “map” of your incident. 2.Compare this with normal acceptable practice (based on national and local policy/guidance) 3.List the changes. 4.Did the changes contribute to the incident? 5.Agree the main problems (CDP/SDPs).

Content from National Patient Safety Agency material Mapping – the chronology of the incident What actually happened - Patient journey Xxx xxxxxxxxXxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx

Content from National Patient Safety Agency material What should have happened - Policy / Clinical guidelines Xxx xxxxxxx xxx xxxxxx xxxxxx Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx What actually happened - Patient journey Xxx xxxxxxxxXxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx Mapping – accepted practice

Content from National Patient Safety Agency material Change Analysis – to identify CDPS & SDPs B. What should have happened - Policy / Clinical guidelines Xxx xxxxxxx xxx xxxxxx xxxxxx Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx A. What actually happened - Patient journey Xxx xxxxxxxxXxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx 1. Variations from acceptable practice - Care & service delivery problems Xxxx xxxxxxx xxxxxxxxxxx xxxxxxxxxxxxx xxx Xxxxxxxxxxx xxxxxxxxx xxxxxxxx xx xxxxxxxxx

Content from National Patient Safety Agency material Worked example Mr Smith, 48yrs – diabetic steel worker scheduled for Right below knee amputation due to circulatory problems. Also problems with Left leg requiring amputation at a later date. After surgery they discovered that the wrong leg had been amputated.

Content from National Patient Safety Agency material Normal procedureIncident Was there a change? Did change contribute to incident? Surgeon knew patient’s condition - both feet gangrenous No Theatre list correct & reviewed by surgeon after typing Theatre list changed and hand written by SHO (RIGHT leg not clearly identified) Yes Marking of site by surgeon prior to list using skin pencil, after checking with pt and notes Right calf marked by SHO using Biro when consent form signed. Patient crossed legs & mark transferred to left leg Yes Preparation & draping carried out by surgeon Preparation & draping carried out by surgical assistant who did not know patient Yes Change analysis

Content from National Patient Safety Agency material What should your CDPs/SDPs look like? Specific not vague: Communication failure X Paramedic failed to inform A&E patient was confused What happened not why: Not enough training on hand hygiene X Staff member did not wash or clean his hands

Content from National Patient Safety Agency material Changes (CDPs) leading to the incident SHO produced an unclear hand written theatre list SHO marked the site using a Biro Surgical assistant draped limb after reading theatre list and noting site - omitted to check medical records and consent form Draping not carried out by surgeon

Content from National Patient Safety Agency material Care should be taken to avoid:- Hindsight bias = Judging with the benefit of knowledge others did not have at the time of the incident. This leads people to make unfair assumptions about staff closest to the incident. Outcome bias = If an error causes no harm it is considered lucky. If the same error causes significant harm we are more likely to blame. This allows accountability to become inconsistent and unfair.

Content from National Patient Safety Agency material Group work 1.Verify unconfirmed facts (Try questioning your presenter/facilitator) 2.Identify CDPs and SDPs 3.Define the failing not the cause (Use clear & specific phrasing)

Content from National Patient Safety Agency material Why are CDPs and SDPs so important? 1.To break down the analysis into manageable chunks 2.To provide a forum for raising / referring perceived blame issues 3.To ensure that both clinical care + service delivery issues (unsafe acts & conditions) are considered equally as appropriate 4.To provide a means of prioritising in line with capacity and resource limitations.

Content from National Patient Safety Agency material How to conduct an adapted NGT Participants... 1.Generate a list of CDPs & SDPs using Change analysis 2.Combine or eliminate duplicate ideas. 3.Individually vote on CDPs/SDPs considered most influential 4.Rank/prioritise CDPs & SDPs in line with votes cast

Content from National Patient Safety Agency material Group work (Cont) 4.Combine similar issues into one CPD/SDP 5.Prioritise CDPs and SDPs for further analysis

Content from National Patient Safety Agency material Key Points – CDPs and SDPs A really important bit! Concentrate on correct phrasing of CDPs + SDPs Allow carefully facilitated exploration of perceived blame issues - at this stage only