What the judges said:
The submission from the team at Bradford, demonstrates how organisations learn from error, co-design a process to prevent re-occurrence and share the learning in a collaborative way. Through simple steps and streamlined communication, the project outlines how the improvement led by the teams themselves, can make a difference to the care pathways and escalation of patients presenting at risk of clinical deterioration.
When the Emergency Department (ED) at Bradford analysed a cluster of serious incidents around deteriorating patients, they found four areas of concern. They addressed these through a combination of simple solutions which, through teamwork and sustained attention, have significantly improved the safety of ED patients at risk of deterioration.
The ED is a large department with a wide range of staff on different shift patterns. This meant that is was sometimes hard for staff to identify the senior staff on shift to whom issues and problems should be escalated. Now team leaders have badges that clearly identify them, making quick escalation easier. Someone with a badge is always on the floor. If a team leader goes on a break, even for thirty minutes, they hand over the badge to someone else so that a team leader is always visibly available.
The serious incident analysis found variation between doctors in how fluids were prescribed for patients. So they standardised the policy for prescribing fluids and ensured, through daily handovers, posters and education, that all clinical staff understand it. The result is easier and more consistent administration of fluids. Further, any clinician taking over a patient now knows the fluid regime that they are following, reducing the prospect of variation or error.
When a clinician sees an abnormal result in a patient’s blood gas test, they are supposed to bring it to the attention of the ED consultant. Yet the serious incident analysis showed that, in some cases, this didn’t happen consistently. Perhaps this was because the parameters for what constituted ‘abnormal’ were not clear. Or perhaps some of the less commonly problematic blood markers, such as potassium, were being overlooked when the more common ones, such as oxygen, were within normal bounds. So the team published a standard set of blood gas parameters. They put these on posters, briefed the team at handover and put them on the machine that tested blood gases. Now if any test result exceeds these parameters, the response is simple: escalate to a consultant.
ED consultants can be pulled into different cases at random times while at the same time answering queries from anyone in the department. As a result, several hours may pass for an individual patient between successive checks by a consultant – which may increase the risk of unchecked deterioration. To address this, ED consultants have adopted a routine of rounds every two hours. This has increased patient safety, as patients are routinely reviewed at two-hourly intervals, reducing the chance of unnoticed deterioration. It has also had an unexpected benefit: consultants are bothered less by random queries. Registrars and nurses know that the consultant will be coming along shortly, so are prepared to wait a short while if a query is not pressing.
Each change was simple. They cost very little. But their effect has been significant. Where six serious incidents around deteriorating patients were reported in 2016, none have been reported to date in 2018 since these changes have been made.
Despite being simple, making the changes has not been easy. It has required persistent, dedicated attention from all concerned. It has needed a multi-disciplinary team, so that proposed changes have been designed and implemented in ways that work for all. It has been tied to education, so that the new changes have been incorporated into the ED’s monthly in-situ training.
Above all, it has required sustained, regular and consistent messaging and attention from the departmental senior team over at least three months. This has been aided by their commitment to report their progress monthly to a Trust-wide collaborative on deteriorating patients; this has helped to sustain their focus.
The success of this project seems to us to come down to three things. First, Bradford ED analysed incidents not to identify blame but to understand specific causes. Second, they developed, as a team, solutions to each cause that were simple, practical and made it easier to do the right thing. And third, they promoted and sustained these changes through consistent, persistent messaging.
The result is safer patients and, by the sounds of things, some slightly easier ways of doing things. And that has to be good.