Situation: Safer Clinical Systems in Healthcare
When we get dressed each day, our briefs are a vital part of our routine. In the context of healthcare settings, safety briefs are also a vital part of our routine and I hope that this short piece will enlighten you as to why.
There is a proactive approach to changing healthcare systems happening currently within our hospital. It is sponsored by the Health Foundation and you may have heard the words ‘Safer Clinical Systems’ uttered recently. This is being carried out by all willing bodies that work on ward 7, which is our medical admissions unit. A core multidisciplinary team decided to focus on making prescribing safer within our medical admissions unit, but this approach can be adapted to any setting both in primary and secondary care.
We have undertaken a lot of work to proactively understand our prescribing system and where it causes the most harm to patients. We achieved this via the guidance issued by the Safer Clinical Systems programme by using of range of tools including process mapping, hierarchical task analysis, audit and analysing human factors. Harm is a term used to describe when care results in a negative impact on a patient’s quality of life; or put simply, something happens to them that you would not wish to happen to your own family. We all have a professional duty to minimise the likelihood of making mistakes and reflecting on them when they occur, but sometimes it is difficult to influence change in such complex systems. We are working on several interventions to improve multiple aspects of our prescribing system and we thought it would be useful to share the success of a relatively simple intervention that could be applied to most clinical areas in primary or secondary care.
When we analysed our system, we knew that a lot of prescribing activity happens on the post take ward rounds, which is where the duty consultant reviews the patient for the first time. Group discussions and audit work revealed that sometimes we forget to make sure that all our hard work involved in making treatment decisions is then carried out for every patient in a timely manner. There are many reasons why this can occur; staff joining and leaving throughout the round due to other emergencies, complex cases being discussed in a busy environment, high admission rates, but most importantly we are all human and sometimes we forget to pass on information, misread a situation or make a mistake.
For example, a patient on ward A is boarded to ward B because ward A is at capacity. The patient is not reviewed by the team until they have finished the ward A round. The middle grader mentions that the team only have one patient left to see who needs discharged, but they are boarding in ward B. The team review the patient and agree that they can be discharged, however it is now lunchtime and the patient’s relatives arrive and are ready to take them home. The discharge letter has not been completed so the family are frustrated as they were informed of the potential discharge yesterday.
No one ever sets out to harm or cause distress to their patients that day, but sometimes the way in which we work in a system makes it difficult to provide reliably safe care. So what could we do differently? How about asking the MDT to trial a brief and debrief on each of their ward rounds. The clue is in the name, ’brief’. Most days we remember to pass on all relevant information to our team members, but our capacity to cope with rising stress levels reaches a limit which can lead to mistakes. These principles are commonly discussed in team resource management training adapted from aviation, which have extensively utilised briefs and debriefs to improve their crew safety. The brief is important to ensure that all of your team members know each other’s name as this makes them more likely to make challenges when you may be working with new faces. It is also important to gather the team to prioritise what is going to happen, as sometimes the team just want to get on without thinking about how to do it i.e. our annoyed relatives and delayed discharge could have been prevented by asking which patients do we need to see first or confirming whether the discharge letter had been completed in advance?
The debrief at the end of the ward round serves to recap on each patient which means that everyone has the same shared understanding about the treatment plan, and provides an opportunity to mention anything they may have originally missed. It also allows tasks to be allocated to an individual so that the team have clarity of what still needs to be done and who will do it i.e. Dr A will take a gentamicin level at 10pm and Dr B will review the level and re-prescribe the next dose for tomorrow morning.
Here are our key components for what your brief and debrief should contain:
• Gather the MDT-do not start until all key personnel are present otherwise you may miss a vital piece of information!
• Prioritise which patients need to be seen first
• Regather the MDT
• Give an SBAR overview of each patient to ensure a shared team understanding
(SBAR stands for situation, background, assessment and recommendation)
• Ensure any outstanding tasks are clarified by assigning the who, what, why and when
Do you currently do this in your clinical area? If not, discuss this with your MDT and decide when you can try this out and who you need to invite to your brief and debrief. Each time you try this, ask everyone at the end what they thought of it and keep a note of the any items that you all highlighted that otherwise would have been missed i.e. was that blood form put out? Has the social work referral been done? Can you prioritise this first? This also provides staff with a training opportunity on how to succinctly communicate important aspects of clinical information. The key components can be expanded to suit your team’s needs. If people like it, they will gradually adopt the process and you have made your system safer by making a small change which also improves team work.
Laura Graham is a Clinical Pharmacist and Lead for the Safer Clinical Systems Project at DGRI
Next Week: @andyecc71 tells us about his experiences with the media.