B2 Denise Hudson - Quality Forum 2015

Establishing a pediatric
safety reporting program
Quality Forum 2013
How do we translate research into action?
Formed task force
Denise Hudson, BC PSLS
Suzanne Steenburgh, Program Manager
Tex Kissoon, VP Medical Affairs
Pat Gillis, Director Volunteer Resources
Laurie Johnson, Quality and Safety leader
Tricia McBain, Director, Quality, Safety BCCH & SH
Tracie Northway, Strategic Implementation
Susan Greig, Partners in care family liaison
The problem…
• More than 9% of children in hospitals in Canada
experience an adverse event
• The risk of having an adverse event was nearly 3-fold
higher in academic pediatric centers than in
community hospitals
Adverse Events Among Children in Canadian Hospitals:
The Canadian Paediatric Adverse Events Study
Matlow AG, Baker R, et al (2012)
How can patients and families help?
“When patients and families tell their own stories to
members of a clinical care system, the organizational
culture begins to reflect patient-centeredness. These
stories slowly shape the way clinicians speak, think,
and behave toward patients…..”
Order from Chaos: Accelerating Care Integration
The Lucian Leape Institute (October, 2012)
Face-to-face patient and family engagement model,
deploying volunteers with a laptop computer to seek
the patient and family’s view on safety
Patient Reporting for a Safe Environment
• 5-year project in UK (National Institute of Health
• Tested telephone line, paper and pencil, face-to-face
• Patient volunteers collecting data from patients;
tools hosted on a tablet personal computer (July
BMC Health Services Research
Ward, et al (2011)
Great Ormond Street Hospital
London, UK
Awarded a national grant for SHINE project
Recruited 2 dedicated full-time staff
Pilot on one ward over the next 15 months
Trialing version of “Patient’s View” application
Stollery Children’s Hospital
Edmonton, AB
• Interest in implementing similar program
• Shared tools developed for Patient’s View with
clinical quality team at Stollery
Go Live! August 15, 2012
• Selected Surgical Unit as pilot site
• Engaged clinical staff on ward
• Branded the project
• Recruited eight volunteers and provided education
• Volunteers engage families
• Families report safety concerns at the bedside using
a laptop and a tested, validated web-based tool
• Quality Leader reviews reports
• Staff and leaders use feedback for action planning
and quality improvement
Was the pilot a success?
• Volunteer success
• Organization success
– Process measures
• Family participation rate
• Validity of reports as safety concerns
• Usefulness of reports to inform QI efforts
• Family success
– Satisfaction with process
• Balancing measures
Volunteer Success
Volunteers report a positive experience where they feel supported
and valued and feel they have contributed to safe care at BCCH
Volunteers rate their experience:
Suggestions for improvement?
“…more communication with the charge nurse to let
her know the days volunteers are coming…”
“A faster and easier to carry tablet (i.e. an iPad).”
“…having a list of patients being discharged on hand
when you are on the shift…”
Evaluation of orientation process:
Making a difference for patient safety?
Would you recommend this experience?
“I think it is a great way to interact with the
families/patients that is different from other volunteer
roles because you have a purpose and topic of
conversation. It gives great insight into their
experience and has made me more empathetic to the
patients and families situations at BC Children's
Hospital. For those volunteers looking to pursue a
career in any sort of health care I feel this is a valuable
Process measure:
Family participation rate
65% of shifts available had a volunteer assigned
Sept. 10th – Nov. 19th, 2012:
420 discharges (total)
109 on weekends (no coverage)
311 on weekdays (covered by volunteers)
100/311 families identified by CN as appropriate
3 declined participation
46 sleeping, out of room, bad timing, etc.
51 participated
51% of eligible families participated = 12% of total discharges
Process measure:
Validity of reports
Patient’s View =
76 safety concerns reported
92% (70/76) assessed as valid safety concerns
What did patients and families tell us?
Medication problems:
Do you think a problem with
medication or IV fluid occurred?
• Dose missed?
• Too much given?
• Too little given?
• Incorrect time, rate, route, medicine?
• Incorrect patient?
• Insufficient pain medicine?
• Medication history incorrect?
Complications of care:
Do you think a complication of care
occurred or was stopped before
• Procedure or treatment was not
followed correctly
• Test was done incorrectly
• Poor sterile procedure or care
• Changes in care made too rapidly
Equipment problems:
When equipment fails or is not used
• Equipment failure caused a risk
• Intravenous or arterial line did not
work correctly
• Equipment was incorrectly used
• Device was not available when
• Room ill-equipped
Miscommunication between staff:
When members of the staff give
information or receive information
from other staff about diagnosis,
treatment or care that is
inadequate, conflicting or incorrect
• Information not shared among
healthcare providers
• Test repeated because original was
lost or destroyed
• Documentation was incorrect or
Miscommunication between family and staff:
“I think there has been a huge disjoint
between myself the parent and the
‘team’. I don’t think I have been kept
informed on a number of instances,
from a medication being discontinued,
to another medication from home
being thrown out, to results of tests
not being disclosed. I don’t think the
different services work well together,
and different information gets given
by different people. It is all very
frustrating and hard to feel confident
that things are correct and not being
Other problems reported:
When any action, not previously
described, fails or is the incorrect
Confidentiality not respected
Not given due respect
Verbally assaulted
Physically assaulted
Please describe anything you noticed staff or
the hospital doing to help promote safe care
Family satisfaction with process of being
asked about safety concerns:
“This conversation is one example of the unbelievable level of
engagement with families within BC Children’s Hospital.”
“One mother actually thanked me after doing the survey because she
found it very therapeutic. I have never had a parent turn me down
or not be appreciative for what we do.” (Patient’s View volunteer)
“I am a business man and have been doing surveys with customers
for years. It is excellent you are initiating this at Children's; I believe
it will make care safer. Thank you!”
QI work informed by Patient’s View
• In progress: Medication Reconciliation and family
involvement in transfer of care
• Update MRSA screening policy
• Standardize process for obtaining urine for R&M
• Standardize post-op pain control for tonsillectomy/
• Revisit process for calling families back to bedside for
• Communication opportunities for staff
Balancing measures:
Number of spurious reports = 0
Number of reports not related to safety = 6
Ward or risk management resources needed for
individual follow-up on family reports = Minimal
6 reports were complaints related to “hotel” aspects (e.g.
food quality, room cleanliness)
51 reports x 5 minutes review = 4.25 hours
Number of volunteers reporting they cannot meet
the expectations of the role = 0
Lessons learned:
 Families are highly motivated to report and happy to
be invited to give feedback on patient safety
 Soliciting reports within 48 hours of discharge
 Web-based reporter form and laptop
 Trained volunteers
 Feedback informs/validates quality improvement
 Patient engagement is essential
 Volunteers benefit from a buddy shift
Next steps?
• Spread to other units
• Utilize tablets/iPads/apps
• Engage families from all ethnicities
and cultures
• Make “Patient’s View” application available on the
• Close the loop with families; results on a web site
• Engage families in improvement projects
Please Contact:
Denise Hudson
Quality Leader, BC PSLS