Published on March 7, 2014
Transitioning Patients Between BC Cancer Agency & Vancouver – Acute Quality Forum February 27, 2014 Sue Fuller Blamey Darren Kopetsky
Case for Change Patient Safety Event with a patient transferred from Vancouver General Hospital (VGH) to BC Cancer Agency for an out-patient Radiation Therapy appointment
Collaboration between BC Cancer Agency and Vancouver General Hospital 2. Patient returns to sending facility due to agitation and disorientation 4. Patient transfers to BCCA escorted by sending hospital nurse 5. Patient arrives in Radiation Therapy Dept at BCCA agitated and in pain 14. Patient assessed as breathing normally with no decreased RR 11. Sending facility nurse gives medication 3. Patient transfer plan created at sending hospital 6. Resident assesses patient and obtains medication from inpatient unit 8. Resident assesses that patient has settled but asks nurse to leave medication with him 10. Resident gives verbal order to the sending facility nurse for medication 15. Patient is transferred back to VGH 16. Resident checks patient status throughout evening with VGH nursing staff 7. Nurse draws up medication in syringe and brings down to RT BCCA Staff physician 1. Patient transfers to BCCA for evaluation for Radiation Therapy 9. Patient is transferred to treatment unit in RT and now requires pain medication 12. Staff physician assesses patient to be stable Radiation Therapist BCCA Nurse BCCA physician resident Nurse – sending facility Patient Transfer of patients from other facilities to Radiation Therapy at BCCA 13. RT gives patient Radiation Therapy •Met with leaders, educators, physicians & frontline staff from both Hospitals •Reviewed transfer process between organizations
Review of Transition Processes Patient Nurse – sending facility BCCA physician resident BCCA Nurse BCCA Staff physician was really complex with many possible ways for the process to fail •Conducted a Failure Modes Effects Analysis (FMEA) to identify defective process steps and mistake-proof the process •Listed the top 12 ways that the process could fail Transfer of patients from another facility to Radiation Therapy at BCCA Radiation Therapist • Realized that the process 1. Patient transfers to BCCA for evaluation for Radiation Therapy 2. Patient returns to sending facility due to agitation and disorientation 4. Patient transfers to BCCA escorted by sending hospital nurse 5. Patient arrives in Radiation Therapy Dept at BCCA agitated and in pain 9. Patient is transferred to treatment unit in RT and now requires pain medication 11. Sending facility nurse gives medication 3. Patient transfer plan created at sending hospital Failure Modes: 1. Nurse not aware of care plan or Nursing summary 2. Does not bring pain meds 3. Care plan lacks pain management 4. Lack of communication about patient needs 14. Patient assessed as breathing normally with no decreased RR 6. Resident assesses patient and obtains medication from inpatient unit 7. Nurse draws up medication in syringe and brings down to RT 8. Resident assesses that patient has settled but asks nurse to leave medication with him Failure Modes: 1. Unclear physician’s order 2. Floor nurse not sticking to 7 rights 3. No after-hours transfer policy 4. No procedure for retrieving medications afterhours Failure Modes: 1. Nurse uneducated on 10. Resident gives BCCA protocol verbal order to the 2. Unclear policy on who can give sending facility pain meds in nurse for BCCA medication 3. VGH staff unaware of RT procedure 15. Patient is transferred back to VGH 16. Resident checks patient status throughout evening with VGH nursing staff Failure Modes: 1. No RN communication back to sending agency 2. No MD followup 3. Interagency communication for planning next trip 12. Staff physician assesses patient to be stable 13. RT gives patient Radiation Therapy
Transfer Failure Modes Prior to transfer During clinic Post clinic 07/21/11 • Lack of communication about patient needs • Nurse unaware of patient care plan • Lack of pain management plan prior to transfer • No medication with patient for transfer • Unclear physician orders • No 7 rights of medication administration • No after-hours policy for retrieving medication at BCCA • Nurse uneducated about BCCA RT protocol • No policy for VCH nurse to give medications • No communication back to sending hospital from BCCA • No written physician follow-up post procedure
Reasons for Failure Modes Unclear procedures for transferring patients to and from VCH and BCCA and retrieving medications after-hours Staff at VGH thought BCCA was part of VGH Minimal planning prior to transfer Is the patient too sick to travel Communication issues between care providers Verbal orders Lack of staff education
Failure Modes Analysis Worksheet
Analysis of Failure Modes List Root Causes Score severity and probability of recurrence of each root cause Identify solutions to mistake-proof each root cause and failure
Recommendations/Solutions 1. 2. 3. 4. 5. Staff at VGH and BCCA need to communicate verbally and in writing prior to patient transfer VGH staff to contact physician prior to transfer if patient condition changes VGH staff education re: RadiationTherapy procedure Discussion at BCCA MAC re: appropriate use of verbal orders Patient requires pain management plan prior to transfer
Recommendations/Solutions 6. Create intra-facility policy on ability for VGH nurses to give medications at BCCA & afterhours medication procurement at BCCA 7. Education re: 7 rights of medication administration 8. Protocols for giving medication after-hours at BCCA
Created Checklists for BCCA and Vancouver – Acute Hospitals
Created Checklists for BCCA and Vancouver – Acute Hospitals
Clinical Practice Document Vancouver – Acute 07/21/11
Recommendations/Solutions 9. BCCA Communication back to sending facilities 10. PHSA Handovers Framework 11. Patients too ill to transfer should be rebooked
Further Work on Handovers & Transitions in Both Organizations Vancouver – Acute •Clinical Practice Document on Transfer of Patients for Tests/Procedures: Patient Accompaniment • expands use of checklist beyond BCCA • identifies when accompaniment is required, and what to consider when using clinical judgment to establish requirements in other scenarios.
Further Work on Handovers & Transitions in Both Organizations PHSA: Handovers and Transitions Framework Addresses three types of hand-offs (Internal, External, Intra-agency). Each PHSA agency or service must include in their processes and procedures the following core elements: a)Standard mechanism of transfer b)Patient/Caregiver involvement c)Interactive communication d)Comprehensive information e)Review of previous history f)Documentation g)Ensure minimal interruptions
5 Nov Dec Jan Feb Mar apr may jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan # of Events Reporting, Measuring & Evaluation Number of BCCA Transitioning Events 30 25 20 15 10 Series1, 4 0
Next Steps – Roll out to other Health Authorities •Transfer Checklist rolled out to Fraser Health – Abbotsford & Surrey and now the rest of Fraser Health in progress •Preliminary meetings with Interior Health and Northern Health to implement program •Meetings arranged with Island Health to discuss potential implementation
Key Learnings Partnerships • Need to collaborate with key stakeholders to get to the bottom of all root causes of the failures Learning about other organizations • Need to understand each other’s process in order to make adjustments to prevent errors Communication • Regularly communication after implementation • Re-implementation of staff education and procedures
Thank you to Original Participants in this Process Original Team Dr. James Morris Lise Belanger Dr. Peter Lim Dr. Ryan Carlson Brendan Tomkins Frankie Goodwin Janice Dirksen Karen Janes Lorraine Blackburn Darren Kopetsky Sue Fuller Blamey Nancy Edge VGH & Vancouver Cancer Centre Prab Gill, Jennifer Tabamo, Iryna Clark, Susan HarrisonSalt, Rita Mah, Sarah Hawley, Priscilla Messier, Katherine Garaghan, Lynn Paddon, Jacqueline Rocheleau, Elizabeth BeddardHuber, Kylie Perrins , Jennifer Rosychuk, Nancy Runzer, Sharon Manship, Mary Flaherty, Sue Fuller Blamey, Tracy Lust ,Jean Carr
Original Team – BCCA & VGH 07/21/11
Thank-you to all other BCCA Leaders & Health Authorities Fraser Health & Fraser Valley Cancer Centre Northern Health – Cancer Centre for the North Sue Gill, Patti Devion, Teresa Ladonna Fehr, Pam Tobin, O’Callaghan, Cherie Taylor, Sharon Della Webb, Andrea Wolowski, Brar, Shannon deBruychere, Chantele Pamplin, Lorna Roe, Tammy Currie, Sue Fuller Blamey, Tracy Lust Tracy Lust, Savik Sidhu, Joy Keeping Sue, FB, Stephanie Aldridge, Cancer Patients Safer Interior Health & Sindi Ahulwalia Hawkins Centre for the Southern Interior Island Health & Vancouver Island Centre Lynda Foley, Heather Cook, June Bianchini, Allison Filewich, John Larmet ,Joyce Pocha, Sandi Broughton Sue Fuller Blamey, Tracy Lust Kelly Nystedt, Caroline Ehmann, Brenda La Prairie, Kathleen Yue, Tracy Lust, Sue Fuller Blamey
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