Undertaking root cause analysis Dr. Peter Woodhouse, Chair, Thrombosis & Thromboprophylaxis Committee, Norfolk & Norwich University Hospital.

~1010 beds ~70,000 adult discharges / year ~70,000 adult day cases / year

VTE prevention programme Comprehensive local clinical guidelines Drug chart Thrombosis Risk Assessment (TRA) Monthly audit of TRA completion, all adult wards HAT root cause analysis Deaths since Jan 2009 Non-fatal since Sept 2009 Monthly ‘HAT report’ published Trustwide Patient information Link Nurses ‘Click for Clots’ intranet site

Thrombosis Risk Assessment (TRA) completion (ward audit)

HAT Root Cause Analysis (RCA) Why do it? To find out why it happened To find out if it could have been avoided To find lessons to be learnt To motivate / engage fellow clinicians – We had seen it work before for C.Difficile

What’s a HAT? Hospital Acquired (or Associated) Thrombosis – DVT or PE during hospital admission What about those who probably had DVT / PE on admission but not initially suspected? – DVT or PE within 90 days of discharge We initially chose ‘within 30 days’ (until April 2010)

How did we find the HATs? Non-fatal – Inpatient anticoagulation (warfarin dosing) service – DVT clinic Fatal – Pathology Liaison & Bereavement Nurse Death certificates PM reports (including Coroner’s)

Root Cause Analysis Case reviewed and sections 1 to 3 completed by member(s) of T&T team. Partially completed form sent to Consultant responsible for index admission to complete Section 4 Completed RCA form returned to T&T team, data collated and entered onto database. Common themes identified Summary results contribute to monthly HAT report

Root Cause Analysis Case reviewed and sections 1 to 3 completed by member(s) of T&T team. Partially completed form sent to Consultant responsible for index admission to complete Section 4 Completed RCA form returned to T&T team, data collated and entered onto database. Common themes identified Summary results contribute to monthly HAT report

Root Cause Analysis Case reviewed and sections 1 to 3 completed by member(s) of T&T team. Partially completed form sent to Consultant responsible for index admission to complete Section 4 Completed RCA form returned to T&T team, data collated and entered onto database. Common themes identified Summary results contribute to monthly HAT report

162 HATs per annum (2010) – 125 non-fatal (62 PE / 63 DVT) – 37 fatal (31 PE / 6 DVT) ~ 2 / 1000 inpatient episodes Location of VTE diagnosis – 46% index admission – 36% readmission – 18% outpatient / community

HAT deaths

HAT Deaths <30 days post-discharge 2009 – Total PE 6 DVT 2010 – Total PE 0 DVT Further 6 PEs, days

Non-fatal HAT

HAT by age & gender Deaths (n=73) Mean age 78 years 51% male 49% female 86% emergency 14% elective Non-fatal (n=165) Mean age 66 years 45% male 55% female 63% emergency 37% elective

HAT by Specialty Deaths (n=73)Non-fatal (n=165)

HAT by Predominant diagnosis Deaths (n=73)Non-fatal (n=165)

Risk assessment and prophylaxis in HAT cases

Compliance with NICE CG92

Root cause of HAT

Problems identified and tackled along the way Failure to risk assess – Education campaign, drug chart risk assessment Delay in first dose of LMWH – ‘Thromboprophylaxis round’ in the evening on orthopaedic wards Unexplained gaps in LMWH prophylaxis – Targeted audit Inappropriately Low-dose LMWH – Tinzaparin 3500 units removed from stock – Education re. correct dosing in renal impairment

Problems identified and tackled along the way Delay in diagnosis and treatment of VTE – Education Failure to prescribe according to the risk assessment – Audit and feedback, re-design drug chart TRA Some VTE events seem to be unpreventable – Maintain morale and commitment to VTE prevention

Using the results of RCA

Trust intranet site Links to local and national guidelines ‘HAT reports’ / audit reports Treatment protocols Patient information Adverse incident reporting ‘Blog for bleeding’ Feedback to anticoagulation service and T&T team

Resources required Specialist Pharmacist Specialist Nurse(s) Pathology Liaison Nurse Two Haematologists Geriatrician Head of Pharmacy IT Web Specialist Supportive management

Any questions?