Never Underestimate the Importance of Briefs for Patient Safety

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.

 
Background

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.

 
Assessment

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.

 
Recommendation

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:

 
Brief

 
• 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

 
Debrief

• 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.

Welcome to dghealth by @kendonaldson

Welcome to the first instalment of dghealth. I have set up this blog as a resource for all employees of Dumfries and Galloway Health Board to share knowledge, ideas and achievements. There will be no theme or corporate vision and I hope the topics, whilst maybe not appealing to everybody all the time, will help spread experience and opinion and ultimately improve communication across NHSDG.

Stimulus

Last November I was introduced to Derek Barron, Associate Nurse Director in Mental Health NHS Ayrshire & Arran, who set up a blog entitled Ayrshirehealth (www.ayrshirehealth.wordpress.com) and his enthusiasm and success spurred me on to do likewise in D&G. Ayrshirehealth has been read by more than 5000 people in over 100 countries and has many guest bloggers from out with NHSAA. Around the same time I was introduced to the wonders of twitter and have since embraced social media and its use in healthcare.

Twitter

I set up my twitter account, @kendonaldson, in 2009. Up to November 2012 I had a grand total of 3 followers, had sent 2 tweets and, clearly, never used it. At a meeting here in Dumfries a friend of mine and prolific tweeter, @Rosgray, posted several tweets which included @kendonaldson. Ros has 400+ followers and within minutes my phone was bleeping away as people started following me. I didn’t really understand at first, why would a renal registrar in London who I hadn’t seen for months suddenly want to follow me? I then attended another meeting in Glasgow where professionals from other Health Boards, who I didn’t know, were coming up to me and asking how the meeting in Dumfries had gone. I was astonished that a few simple tweets had touched so many people and began to realise the power of social media.

I now have 49 followers (OK, not that impressive I know) and visit Twitter at least once a day if not more often and not only have I gleaned a wealth of healthcare information and opinion but I have made a number of very useful contacts too. I have also set up a twitter account for our Renal Unit, @DumfriesRenal and this blog, @dghealth. I am an amateur, there is a lot to learn, but I would encourage you to join me on this journey. As many people keep saying, Social Media is here to stay, lets embrace it and use it and not be frightened of it.

Patients and the public

Social media offers a novel opportunity to break down some of the communication barriers between service providers and service users. There is an assumption that when patients wish to comment on their care they only want to complain but this is not the case. Many wish to feedback positively. Service users now have many options to communicate with providers, if they are willing to listen! In the wake of the Mid-Stafford scandal and the Francis Report we have very little option other than to open our ears. If you take a look at the website Patient Opinion (www.patientopinion.org.uk) you will find many comments from service users, and a great number are positive. Health Boards have the ability to respond to these but, sadly, most responses are typically corporate and do not address the issue. If a patient makes a comment about a specific area then those directly responsible for that area; managers, consultants, senior nurses, should be responding and offering to meet them. If the message is positive then feed that back to all staff involved. It’s the same message as above; lets embrace this, not be frightened of it.

Web Opportunities

There are many ways to utilise the internet, social media and handheld devices to our advantage in healthcare. These include podcasts, apps, blogs, video-linking and even taking photos of interesting lesions on camera phones to send to an expert! I suspect we all use some of these to a certain extent but would be surprised at what else is possible. There are barriers. IT access to the likes of twitter and facebook can be limiting but I have been in discussion with IT here in D&G and believe restrictions to these sites will be relaxed soon.

The Future

Who knows what awaits us around the corner but I would like to think the future will hold one blog a week from dghealth for a long time to come. I have 15 bloggers signed up but will be looking for new contributors soon so if you have an interesting message, an improvement plan that worked, a lesson from a patient, anything that you feel would be worthwhile passing on to fellow D&G employees (and beyond!) then give me a call/email/tweet.

Thanks to @dtbarron for his help and support.

@kendonaldson is a Consultant at Dumfries and Galloway Royal Infirmary

Next Week: Laura Graham, Clinical Pharmacist, will be updating us on the safer Clinical Systems project.