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A New TRIC
An audit tool for multi-patient environments
Sue Ieraci 2013
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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!