Storyboard Entry Form 2015Main author: Jessica Svetz & Lesley JenkinsEmail: Jessica.svetz@wales.nhs.uk & Lesley.jenkins@wales.nhs.uk Telephone:01437 773902

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The word limit is 1500 words including references. Your storyboard will not be accepted if you exceed the word limit.

1. Storyboard title: a clear concise title which describes the work

‘Hywel Dda Sees Red: Reducing the Risks of Medication Error’

2. Brief outline of context: where this improvement work was done; what sort of unit/department; what staff/client groups were involved

Imagine you are a passenger on a flight. How would you feel if people constantly interrupted the pilot during critical pre flight checks? What if they were distracted by a phone call or nearby conversation? Would you worry that they may have missed an important check? And if they missed it, what would be the consequences?

Like the aviation industry, medication preparation and administration are high risk procedures but unlike the cockpit on a plane, hospitals are very busy environments.

‘Seeing Red’ is an initiative designed to ensure patient safety by reducing the risks of medication error by minimising unnecessary interruptions and distractions to staff. The strategy introduces the safe practice initiatives from the aviation industry, such as a distraction free cockpit during critical flight phases. Red safety zones have been designed and introduced within the hospital called ‘Medication Safety Zones’ (MSZ), aimed at protecting

the patient by reducing distractions and interruptions for the nurse, which may increase the risks of error.

The improvement work has been a whole hospital approach involving the medical and surgical wards, Emergency and Day Surgery Unit, patients, public and all staff groups at Withybush General Hospital, Hywel Dda University Health Board.

3. Brief outline of problem: statement of problem; how you set out to tackle it; how it affected patient/client care

Drug errors are a major cause of patient injury in the NHS and our experience is that patients are on increasingly more complex medicine regimes. Arguably, healthcare is in the same risk category as the aviation industry and we should be considering the same safety systems to help keep our patients safe and our staff protected from risk.

Following a serious drug error, observations of practice found nurses commonly interrupted and distracted during medicines management. Working at the point of care, nurses play a key role in the delivery of safe, quality healthcare. Nurses have to make timely and relevant clinical decisions, yet work within environmental conditions that are conducive to error. It has been thought that interruptions during the drug rounds are directly correlated with drug errors (Hitchen, 2008) with nursing staff identifying interruptions and distractions as a key factor (Relihan et al, 2010). Distractions along with mental workload and the physical environment are some of the common human factors that increase risk (Carthey et al, 2010). Therefore it is logical to develop strategies to help reduce the risk of medication errors by minimising unnecessary interruptions and distractions to healthcare staff.

Following an extensive literature review, taking best practise examples both nationally and internationally and utilising practices from the aviation industry, a multifaceted approach was developed which evolved into an improvement project called the ‘Seeing Red Initiative’.

4. Assessment of problem and analysis of its causes: quantified problem; staff involvement; assessment of the cause of problem; solutions/changes needed to make improvements

An audit tool was designed to measure the frequency and type of interruptions and distractions during 2 phases of medicines management; preparation and administration of drug.

Audits were conducted over 2 weeks on acute wards and showed interruptions and distractions were predominantly from co-workers and a major cause of disruption to concentration.

Illustrated are the episodes (N) of intravenous medicines management observed and the frequency and type of interruptions and distractions taking place.

Chart 1-Number of Interruptions per episode by staff groupN=26

Specialist Nurse

Students

Physio/OT

Patient

Ward clerk

HCSW

DR

Staff nurse

0 2 4 6 8 10 12 14 16

5

2

2

1

3

15

5

15

Chart 2-Number of Disruptions by typeN=26

Missing Equipment

Staff 'waiting' to interrupt the nurse

Telephone

Conversation

Noise

0 2 4 6 8 10 12 14 16

2

3

3

15

7

A staff survey was conducted to understand what staff believed were the causes of interruptions and distractions and strategies they believed would be useful.

Noise

Conversation

Non task related conversation

Telephone

Missing medicine

Staff 'waiting to interrupt'

Other0

102030405060

2741

21

51

13

50

2

In your opinion, what are the most common types of distractions?

Nurse

Patien

t

Physio

Doctor

Visito

r OTHCSW

Telep

hone call

Spec

ialist

nurse

Ward

clerk

s

Studen

ts

Hotel Fa

cilities

Other

0102030405060

30 27

7

49

31

614

52

817

7 6 1

In your opinion, what are the most common staff groups interrupting?

Staff ed

ucation

Signag

e

Visible

symbols

Red ta

bards

Physical

envir

onment

Training

Other0

153045 40

1029

4229 31

3

In your opinion, what would have the greatest impact on reducing distractions

and interruptions?

Findings: were fed back to staff and four key strategies developed:-

1. Environmental Improvements a. Introduction of Medication Safety Zones (MSZ) to prepare

medications in a quiet, interruption free zone.

2. Clothing a. Wearing Red Tabards - designed to signal to others the need

to avoid interrupting or distracting b. ‘Standard Operating Procedure for Red Tabards’, developed

to emphasise personal accountability and procedure for use

3. Staff Education a. Training co-workers not interrupt or distract their colleague

and to "field" interruptions when they ‘see red’b. Whole hospital awareness raisingc. Training on the importance of ‘essential task related

conversation only’ d. Utilising risk mitigation strategies if interrupted by working

through the ‘8 rights’ checklist to help refocus

4. Patient engagement a. Patient information leaflet explaining the initiative

5. Strategy for change: how the proposed change was implemented; clear client or staff group described; explain how you disseminated the results of the analysis and plans for change to the groups involved with/affected by the planned change; include a timetable for change

Change was planned over 6 months beginning with sharing lessons learnt from adverse incidents with nurses and Doctors. Staff were involved in observational audits to help shift thinking on the risks that were being observed in practice. This shaped four key strategies and influenced large scale culture change.

A multi-professional training programme (i.e. nurses, Junior Doctors, Consultants, healthcare support workers, ward clerks, therapists and hotel facilities) supported implementation and is incorporated into newly registered nurses and new Doctor training. This affords an opportunity for staff feedback and to source ideas for future improvements to help embed cultural change. A training video has been produced to reinforce the messages and is available on the intranet for staff: http://www.filmcafe.co.uk/downloads/MedicationSafetyZone-4.mp4

Patients and relatives awareness is paramount and an easy read information leaflet has been developed with advice from the reader’s panel, low vision committee and learning and disabilities, which has been incorporated in our inpatient information bedside folder. Physical changes were made to each ward. The principles of the sterile cockpit methodology were applied to the Ward environment by the design of Medication Safety Zones (MSZ). The essence of the MSZ is designing a physical space that has a red door/or curtain, a red floor and red signs and staff wearing red tabards to signal to others they are operating a high risk procedure.

Red floor Red door/sign Red tabard

Poster: Medication Safety Zone Rules

‘8 Rights’ Poster to help staff refocus

A launch week in October increased wider public and staff awareness. Strategically located information stands in the hospital gained over 250 signatures from public, patients and staff, which viewed the initiative as positive and necessary. Following on from the success of the project, the initiative will be rolled out across the Health Board.

6. Measurement of improvement: details of how the effects of the planned changes were measured

Post observational audits and staff surveys were undertaken to measure the effectiveness and determine areas that still needed to be addressed.

Noise

Conversation

Telephone

Staff 'waiting' to interrupt the nurse

Missing Medicine

0 1 2 3 4 5 6 7

5

7

3

3

1

0

0

0

0

0

Elimination of Observed Distractions Post Intervention

PostPre

Graph represents 26 pre intervention observations and 22 post intervention observations

Specialist Nurse

Physio/OT

Ward Clerk

HCSW

Patient

Dr

Staff Nurse

0 1 2 3 4 5 6 7 8 9 103

2

3

10

0

5

10

0

0

0

1

1

0

0

Significant Reduction of Interruptions Post Intervention

PostPre

Graph represents 26 pre intervention observations and 22 post intervention observations

Red ta

bards

Staff ed

ucation

Signag

e

Training a

bout Ster

ile Cockp

it

Change

s in th

e physi

cal en

vironmen

t0246

6 6

21

6

In your opinion, what is having the greatest impact on reducing distractions/interrup-

tions?

Nurse Doctor HCSW Ward clerks Patient Visitor Telephone call Physio Hotel Facilities0

1

2

3

4

5

6

7

8

9

2

8

2

3

4

3

5

1

2

In your opinion, what are still the most common types of interruptions?

Telephone Staff 'waiting to interrupt'

Conversation Missing medicine Non task related conversation

0123456789

3

8

2 21

What in you opinion are still the most common types of distrations?

7. Effects of changes: statement of the effects of the change; how far these changes resolve the problem that triggered the work; how this improved patient/client care; the problems encountered with the process of changes or with the changes

Reduction in interruptions and distractions, particularly in the preparation phase, which from a human factors approach correlates in the literature to a decrease risk of medication errors occurring.

Positive impact on optimising the environment for staff to operate. Staff report they ‘feel safer’, patients have commented they feel more confident they are getting the right care and having the undivided attention of the nurse.

Challenges included resistance and low tolerance for change from some staff, operational pressures affecting availability for training, and sufficient time to affect culture change and sustainability.

8. Lessons learnt: statement of lessons learnt from the work; what would be done differently next time

It takes time to change culture; it is recognised this initiative is a continuous process of engagement and collaboration being sought from staff and patients. More time for initial staff engagement would test resistance and tolerance for change.

Branding the project ‘Seeing Red’ with a logo design has created a clear strategy and expectation of staff behaviour. It also represents an organisational culture that we are trying to do everything we can for patient safety.

A key to sustainability is the importance of continuing: • Critical incident monitoring• Direct observations

• Adverse drug event reports• On going education and training • Modelling behaviours by leaders• Driving personal accountability• Integration of audit into Ward safety audits

9. Message for others: statement of the main message you would like to convey to others, based on the experience described

Patient medicines regimes are increasingly complex and working in highly interruptive healthcare environments, have become the norm for professionals. We have a responsibility to our patients to minimise the environmental conditions that are conducive to error.

‘Seeing Red’ offers a simple and practical approach to tackling human factors issues that can increase the risks of drug error. We can ALL contribute to creating a positive culture of human behaviour that recognises the impact of our own behaviour on others and collectively, we can reduce the risk of doing further harm to patients trusted in our care.

Support from general management and the service improvement team have been key to driving the programme of change.

‘Please remember when you see redto respect my need to concentrateand do not interrupt or distract me’

10. Please summarise how your entry reflects the principles of prudent healthcare: you can find out more about prudent healthcare at http://www.prudenthealthcare.org.uk/

This project is about one key Prudent Healthcare principle, do not harm but it is much more than that. It is creating a culture which seeks out evidenced based practice, stimulates innovation from staff and nurtures a mind set of continuous improvement. The service improvement PDSA cycle is about testing small changes to make a beneficially difference. This project is a PDSA cycle on a large scale about changing the culture to enable and embed Prudent Healthcare principles. It is about developing, supporting and giving the confidence to staff to make the changes to improve patient care.

References

Carthey, J. and Clarke, J. (2010) Implementing Human Factors in healthcare. Patient Safety First

Hitchen, L. (2008) Frequent interruptions linked to drug errors. British Medical Journal. 336 (7654), pp.1155-1155.

Relihan, E. et al. (2010) The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Qual Saf Health Care. 19 (5), e. 52.

The NHS Wales Awards are organised by the 1000 Lives Improvement service in Public Health Wales.

www.1000livesi.wales.nhs.uk