undertaking root cause analysis dr. peter woodhouse, chair, thrombosis & thromboprophylaxis...
TRANSCRIPT
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)
37 39 42 46
7585 89 94 95 93 92 97 95 96 97
63 61 58 54
2515 11 6 5 7 8 3 5 4 3
0102030405060708090
100O
ct-0
9
Nov
-09
Dec
-09
Jan-
10
Feb-
10
Mar
-10
Apr-
10
May
-10
Jun-
10
Jul-1
0
Aug-
10
Sep-
10
Oct
-10
Nov
-10
Dec
-10
% TRA not completed
TRA completed
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 2009-2010
HAT Deaths <30 days post-discharge
• 2009–Total 36
• 30 PE• 6 DVT
• 2010–Total 31
• 31 PE• 0 DVT
• Further 6 PEs, 30-90 days
Non-fatal HAT 2009-2010
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
Hospital Associated Thrombosis (HAT) Monthly Report
December 2010
Liz Lorie, Specialist Nurse,Nicola Korn, Specialist PharmacistHamish Lyall, HaematologistJennie Wimperis, HaematologistPeter Woodhouse, Chair, T&T Committee
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?