A New TRIC

An audit tool for multi-patient environments

Sue Ieraci 2013

Sue Ieraci 2013

What’s the Issue?A simple formula:

Focus on quality and safety+

Risk-aversion+

Unsophisticated clinical governance tools

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What do we have now?Some format/combination of:• “Incident” reporting• Severity coding• ‘’Incident’’ Investigation• +/- Root Cause Analysis• Implementation of recommendations• Implementation audit

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Anything wrong with RCAs?• Just one tool• Assumes there is always a ‘’root cause’’• Looks at individual patient care• Linear, not contextual• Focus on identifying errors• Doesn’t recognise an ‘’acceptable’’ error rate• Recommendations often not reality-tested

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Acceptable complication rates

There is an accepted complication rate for:• Surgical procedures• Central line insertion• Therapeutic substances........

But NOT for COGNITIVE processes

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‘’The London Protocol’’SYSTEMS ANALYSIS OF CLINICAL INCIDENTS

• Clinical Safety Research Unit, Imperial College London

• Beyond the RCA

• “Beyond the more usual identification of fault and blame.’’

• ‘’If the purpose is to achieve a safer healthcare system, then finding out what happened and why is only a way station in the analysis. The real purpose is to use the incident to reflect on what it reveals about the gaps and inadequacies in the healthcare system.’’

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Why something different for EDs?THE MULTI-PATIENT ENVIRONMENT

• Multiple patients with competing interests• Prioritisation and compromise inevitable• Interruption and multi-tasking• Concurrent vs sequential patients• Undifferentiated patients• Team-input to process and outcomes• Patient journey• Everyone else has hindsight

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Proposed methodology

TEAM REVIEW IN CONTEXTPrinciples:

• Examine the performance of the clinical team, in the context

of the ‘’episode’’• Use only the information available at the time (no benefit of

hindsight)• Consider whether the team-members involved in the complex

event made either cognitive or prioritisation errors with the resources and completing demands existing at the time

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Components of the tool

1. Task complexity analysis / Process mapping

2. Prioritisation analysis

3. Cognitive analysis

4. Improvement potential analysis

5. Reality testing of recommendations

6. Conclusion

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Task complexity analysis / Process mapping

• identifies the entire scope of the competing demands for care that were occurring during the episode and

• maps the care pathways of individual patients

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Prioritisation analysis

• Examine competing priorities according to urgency of time-criticality for intervention and

• assesses whether there may have been avoidable errors in prioritisation that have impacted on patient outcomes

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Cognitive analysis

• evaluation of the clinical decisions made by the individuals involved in the episode

• using only the information available at the time

• to look for any avoidable cognitive errorsCroskerry

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Improvement potential analysis

• Could any any aspect of care potentially be sustainably improved within realistic resources?

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Reality testing of recommendations

• Would any proposed recommendations realistically have changed the outcome?

• Are they are realistically achievable?

• Could they cause unintended consequences?

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Conclusion

• Summarises the findings of the process

It is an acceptable option to conclude that no recommendations arise as a result of application of the tool.

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Other essential features

• At least one team-member present at the time of the episode is on the team

• Team members are only given information that was available at the time

• The application of the tool should be recorded in the order of the steps specified above, so that each component flows logically into the next, and into a conclusion.

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Acknowledgements

Cognitive collaborators

Philip Hoyle – Clinical governance

Deniz Tek – Cognitive error and cognitive autopsy

Spiritual Collaborators

All those people who have suffered the consequences of inappropriate or poorly-executed RCAs

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A NEAT TRIC!