The Clatterbridge Cancer Centre
NHS Foundation Trust
Sign Up To Safety
Safety Improvement Plan
June 2015
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Table of Contents
Introduction 3
Aims of the CCC Safety Improvement Plan 6
Delivering the CCC Safety Improvement Plan 6
CCC Measurement, Monitoring and Improvement diagram 7
Improvement domains 8
NHS Safety Thermometer denoted avoidable harms 8
Medicines Safety 9
Prevention of medication errors (including prescribing and dispensing) 9
Improve preventative measures to reduce chemotherapy induced nausea and vomiting 17
Implement NICE allergy guidance 19
Improve MHRA yellow card reporting 19
Improve prevention, recognition and management of the adult deteriorating patient 19
Development and Implementation of a Radiotherapy Safety Thermometer 21
Safety Improvement Plan – overview (90 day cycle) to 30th September 2015 23
Introduction
The Clatterbridge Cancer Centre NHS Foundation Trust (hereafter referred to as CCC) is committed to delivering high quality care and to taking action to reduce harm to the patients in our care.
CCC is supporting NHS England’s national Sign Up To Safety campaign and the goal to reduce avoidable harm by 50% and saving 6,000 lives. Through participating in Sign Up To Safety, CCC commits it’s Trust Board and staff to:
1. Put safety first
Patient Safety is at the heart of the Trust Quality Strategy. We are committed to reducing avoidable harm and have decided to focus our plan on the following four Improvement Domains:
· NHS Safety Thermometer denoted avoidable harms
· Medicines Safety
· Improve prevention, recognition and management of the adult deteriorating patient
· Development and implementation of a Radiotherapy Safety Thermometer
2. Continually learn
We aim to continuously learn from our staff and our patients to improve care and safety. We will build on our current systems to further embed a culture of learning.
We conducted our first Safety Culture Survey in August 2014. We will ensure we act on the feedback from all staff and will continue to conduct these surveys every two years across the Trust and more frequently in departments where we need to focus on improvement.
As a result of our first Safety Culture Survey we will introduce new systems to improve feedback on incident reports and investigations. We will also focus more on investigating near misses.
3. Honesty
We are committed to being transparent about the quality and safety of our services. We believe that the public have a right to know about how their specialist cancer centre is performing in the areas that are important to them. We have developed a ‘High Quality & Safe Care’ section on our public website which includes information on key areas of quality and safety such as harm free care, waiting times, complaints, cleanliness, and patients and staff opinion of our hospitals. This information can be found under the following headers:
Safe - Open and honest care, safety thermometer, medicines thermometer, healthcare associated infections, patient led assessment of the care environment, incident reports, Sign Up to Safety
Effective - Compliance with patient risk assessments, 30 day mortality post treatment
Caring - Ward nursing staff levels, patient feedback
Responsive - Compliance with cancer waiting times
Well led - Integrated performance report, staff feedback, nursing care indicators, quality accounts
We will build on the amount of information that we provide including feedback from patients and the public via a web questionnaire to ensure that the information is what patients want to see and that it is easy to understand.
We plan to further develop this website to include benchmarks of how we perform against other Trusts.
Transparency of Care
We are committed to ensure that patients who use our services can easily see information about how we are performing and developing. Our Wards currently display a large amount of information. We are committed to reviewing and further developing this information to ensure it is comprehensive, is easily understandable and meets patients’ needs. We will work with our clinical experts, ward leaders and our Patient Council to achieve this. We will then look to roll this out to other clinical areas.
Patient Stories
We have a programme of videoing patient stories and presenting these at each Public Board Meeting and our Council of Governors meeting. We will further develop this programme in conjunction with our public Governors and will roll out the use of patient story videos to all clinical departments.
4. Collaborate
Patient Pathways
We have recently appointed a Cancer Pathways Project Manager for Network Cancer pathways, he will lead a project to review and improve cancer pathways across the Cheshire & Merseyside network of cancer services. The project will involve complex analysis of cancer pathways, comparison with national best practice, development of recommendations to improve the cancer patient’s journey through the health and social care system, reporting the recommendations to participating hospitals and working with managers in acute hospitals to ensure that recommendations are implemented.
Patients at the Heart of Safety
Patients are at the heart of the care and treatment that we provide and will experience and see things in a different way to staff. We will work with patients to improve safety including implementing a system where we encourage patients, carers and visitors to be able to easily report any safety concerns that they have.
5. Support
Training and Development
As a result of our first Safety Culture Survey we will introduce Health and Safety briefings for staff in all departments focusing on key health and safety themes throughout the year.
We will support staff to improve safety, including medicines safety, by implementing a new Patient Safety Training Program
This will include:
• Root Cause Analysis Master Class for staff who investigate safety issues
• Develop a program of training in Human Factors for Healthcare
We will also review our processes and systems for providing support for staff who raise concerns or are involved in an incident, complaint or claim.
Aims of the CCC Safety Improvement Plan
This Safety Improvement Plan sits within the CCC’s Quality Strategy. The Quality Strategy commits CCC and its entire staff to improve the quality of patient care that is delivered to our patients.
The Measurement, Improvement and Monitoring diagram (over page) details the work-streams within the Trust dedicated to improving patient safety and reducing avoidable harm. We have identified key Safety Improvement Domains to focus our improvement work over the next three years.
Delivering the CCC Safety Improvement Plan
The Safety Improvement Plan is a three year project to improve patient safety within the organisation
The CCC Executive sponsor for the Sign Up to Safety campaign is the Director of Nursing and Quality and the Sign up to Safety Lead is the Clinical Governance Manager for Patients Safety (CGM-PS).
The Executive sponsor and Safety lead will lead the implementation and monitoring of the Safety Improvement Plan.
The Clinical Governance Manager for Medication Safety is responsible for the Medicines Improvement domain with the support of the Medicines Safety Team.
The Clinical Governance Manager for Radiation Services is responsible for the Radiotherapy Safety Thermometer Improvement domain with the support of the Clinical Governance Manager for Patient Safety.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
CCC Measurement, Monitoring and Improvement diagram
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Improvement domains
NHS Safety Thermometer denoted avoidable harms
We record all incidences of the Four harms, specified by the NHS Safety Thermometer, which are attributable to CCC across our three inpatient wards.
We use the following criteria for identifying CCC attributable harms:
o VTE (Venous Thromboembolism) – patient has been an inpatient at CCC within the past 90 days.
o Pressure Ulcers – developed 72 or more hours after the patient was admitted.
o Falls – all patient falls are recorded.
o CAUTI – all urinary tract infections associated with a catheter, according to our Infection Control surveillance definitions (rather than simply reporting all patients who have a catheter and a UTI as these may not be directly related).
Incidences of pressure ulcers, falls and VTE are reported via the Trust Incident reporting system and a Route Cause Analysis is conducted for each harm event to establish the cause of the harm and how (if at all) it could have been prevented. All catheterised patients are monitored for urinary tract infections (UTI) and monitoring continues once the catheter is removed to ensure any CAUTI developing up to three days following catheter removal is recorded.
Medicines Safety
Our new medicines safety service promises to deliver improved medicines safety at CCC through innovation in practice, education and implementation of harm free care initiatives.
The medicines safety team plan to focus on the following initiatives:
· Prevention of medication errors (including prescribing and dispensing)
· Improve preventative measures to reduce chemotherapy induced nausea and vomiting
· Implementation of new NICE (National Institute for health and Care Excellence) allergy guidance
· Improve MHRA (Medicines and Healthcare products Regulatory Agency) yellow card reporting
Prevention of medication errors (including prescribing and dispensing)
The medicines safety group (a collection of staff and lay members from a variety of backgrounds) monitor medication errors and strive to implement systems and procedures to prevent them.
Medication Errors are identified through Incident Reporting, VTE Audit and the Medication Safety Thermometer.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Driver Diagram for Medication Errors
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Action Plan for the prevention of Medication Errors
Objective / Action required / Responsibility / By date / Progress1.Prevention of medication errors (including prescribing and dispensing) / Teaching
· Pre reg radiographers
· Student Nurses
· Trainee Doctors
· Two yearly medicines management training
· CD training
· Medicines safety & yellow card for clinical champions / MST / July 2016
2 Improve preventative measures to reduce chemotherapy induced nausea and vomiting / Audit for CINV / CGM-Medicines Safety and Medicines Safety Pharmacist / July 2015
Education / CGM-Medicines Safety and Medicines Safety Pharmacist / October 2015
Review anti-emetics formulary / MST / Sept 2015
3 Implementation of new NICE (National Institute for health and Care Excellence) allergy guidance / Ensure action plan is adhered to and guidance is fully implemented / MST / April 2016 / In process
4 Improve MHRA (Medicines and Healthcare products Regulatory Agency) yellow card reporting / Consider additional training for NMP’s and acute oncology NP’s, ANP’s, CNS’s. / MST / July 2016
Education
· Medicines management training
· PGD pharmacology
· PharmaC
· Outpatients
· Delamere
· SPR’s
· Trainee doctors
· Consultants rolling half day / MST / March 2016
5 Work with Meditech implementation CRG teams / Integrate over all groups of implementation groups / MST / October 2016 / In progress
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Incident Reporting
Medicine related incidents are separated into the following three categories:
· Drug error – wrong drug, wrong route, wrong dose, wrong time, wrong patient
· Dispensing error – near misses associated with dispensing
· Prescribing error – near misses associated with prescribing
All medicine related incidents are reported and discussed at the medicines safety group bi-monthly.
Baseline (2013/14) and first year (2014/15) data for all medicine related incidents are illustrated in the graph below and those on the following pages.
Incidents related to medicines reported since April 2013 broken down by month
As predicated there has been an increase in reporting of medicines related incidents since the introduction of the medicines safety team.Drug Errors since April 2013 broken down by month
Dispensing Errors since April 2013 broken down by month
Prescribing Errors since April 2013 broken down by month
Venous Thromboembolism (VTE) Audit (baseline data 2013/14)
In January 2010 NICE guidance “Venous Thromboembolism: reducing the risk” was issued. This updated guidance specified VTE at risk patients and that patients must be assessed on admission and again for risk of VTE and bleeding within 24 hours of admission and prophylaxis commenced where deemed necessary.
Baseline VTE Audit data for 2013/14. For the purpose of this audit patients prescribed prophylactic treatment but omitted due to a clinical reason, refused, on leave, sent home or self-administered have been counted as compliant.
2014/15 data is currently being ratified.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Medication Safety Thermometer
The Trust signed up to participate in the National Medication Safety Thermometer pilot in April 2014 and has continued to use it to drive medicines safety improvements. The Medication Safety Thermometer data is provided below 2014 – May 2015.
The ’Not documented’ medicines are considered as omitted doses and therefore a medication error. We have seen a significant improvement in the number of omitted medicines since the introduction of the Medicines Safety Thermometer.
Work is ongoing to identify if the ‘‘Med not available’ or ‘Route not available’ errors are avoidable or not.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015 2
Improve preventative measures to reduce chemotherapy induced nausea and vomiting
In the IHI Global Trigger Tool, the definition used for harm is as follows: unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalisation, or that results in death.
We aim to reduce chemotherapy induced nausea and vomiting (CINV), a condition which causes particular distress to cancer patients.
We will take a pro-active approach to the early identification of high risk patients. This will allow us to plan earlier interventions; this work-stream will be led by the medicines safety team.