Implementing the Vincent Framework at the Frontline
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The document discusses the implementation of the Vincent framework within healthcare settings in Scotland, highlighting its application for measuring and monitoring safety, particularly regarding medication errors. It outlines challenges, key learnings from frontline experiences, and emphasizes the importance of involving all stakeholders in this clinical approach. Additionally, it provides resources for further information and training related to patient safety initiatives.
![Medication
Errors
Past Harm
Reliability
Sensitivity to
Operations
Anticipation
and
Preparedness
Integration
and learning
Administration errors [ M]
• Omissions
• Wrong dose
• Wrong medicine
• Wrong time
• Wrong route
• Wrong patient
Patient experience – e.g. adverse reaction to medication [M]
Standardised process
• Start time/format
• Checking/rechecking process
• Attending to emergencies
Shift planning and delegation of roles
Response to patient queries
Having to chase up patients to get their
medication / Not all patients come to
trolley for medication
Complying with medicines
reconciliation
Prescribing Errors - Zero Tolerance
Criteria [M]
Unable to read prescription
Awaiting for medication changes to
occur to dispense
Staff knowledge of patients [measure-monitoring]
Staff knowledge/confidence
Dealing with competing priorities on the ward to protect the drug round
Interruptions from pharmacist, doctor or domestic [ M]
Conversations with patients, what information do they need and want about
what to expect?
(Ward Board & leaflets)
Get hold of Doctor to make TPAR changes
Shift planning (Reliability as well as S.T.O.)
- decide males/females
- breaks planned better
- structure for breakfast group, domestic staff, etc.
Staffing levels [M]
Safety briefing – previous errors (M)
Delegation of known tasks at the beginning of the shift
Well organised drug dispensary/trolley
How we do this rather than measure it
Sharing good practice/poor
practice
Learning from previous errors
Datix reviews/verifiers
Culture of reporting near misses
Patient learning/responsibility
positive risk taking/recovery/self
management
Patient knowledge of Medication
and side effects
Patient self dispensing
Outcome/Learning Top Tips
•Involve Everyone
•Pick a date and get started.
•Bottom Up approach](https://image.slidesharecdn.com/implementingthevincentframeworkatthefrontline-shifttosafety20170223-170224153211/85/Implementing-the-Vincent-Framework-at-the-Frontline-23-320.jpg)
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Implementing the Vincent Framework at the Frontline
- 1. Implementing the Vincent Framework at the Frontline Jo Thomson, Healthcare Improvement Scotland Alison McGurt and Morag MacRae Taysiide Trust Dr. Jonathan Kirk, Healthcare Improvement Scotland Dr. G. Ross Baker, University of Toronto
- 2. Speakers Jo Thomson Senior Programme Manager, Healthcare Improvement Scotland Alison McGurk Clinical Team Manager, GAP NHS Tayside Morag MacRae Patient Safety Development Manager NHS Tayside
- 3. Speakers Dr Jonathan Kirk National Clinical Lead, Measurement and Monitoring of Safety Programme Healthcare Improvement Scotland Dr. G. Ross Baker Institute of Health Policy, Management and Evaluation, University of Toronto
- 4. Welcome
- 5. Using the Framework No action yet Planning for applying the Framework in a clinical setting Started to apply the Framework in a clinical setting
- 6. Jo Thomson How Scotland became involved in the Measuring and Monitoring of Safety Framework
- 7. Measurement and Monitoring of Safety Programme Canadian webex Thursday 23rd February 2017 8 Jo Thomson, Senior Programme Manager @JoThomsonQI e: [email protected]
- 10. 11 NHS Tayside •Mental health unit – initial focus on medicine omissions •Board performance review process NHS Borders •Frailty pathway (point of admission to acute care) •Ward to Board Our testing
- 11. 12 Further information www.howsafeisourcare.com Monthly calls open to all (register at www.howsafeisourcare.com) Next call Wednesday 15th March Interactive pdf (from March 2017) #THFSMP
- 12. Keep in touch…………. e: [email protected] @JoThomsonQI
- 13. 15 Morag MacRae Patient safety development manager Alison McGurk Clinical team manager
- 15. 17
- 20. 22 Through the eyes of patients https://www.youtube.com/watch?v=dBUxnyOxW_4
- 21. MDT communication Past Harm Reliability Sensitivity to Operations Anticipation and Preparedness Integration and learning Safety Planning Past Harm Reliability Sensitivity to Operations Anticipation and Preparedness Integration and learning Safer Medicines Past Harm Reliability Sensitivity to Operations Anticipati on and Prepared ness Integration and learning
- 22. Safer Medicines Past Harm Reliability Sensitivity to Operations Anticipation and Preparedness Integration and learning Medication errors Never events/mortality Inadequate monitoring of high risk Side effects Physical health issues Med rec on admission Med rec on discharge Med rec on transfer High risk medication checklists Adherence to medication policies Systems for monitoring and reviewing medications Current monitoring systems Person dependant processes Variability with processes Leadership on ward Professional accountability Professional responsibility MDT knowledge of medicines policy/protocols Development and dissemination of policies – organisational challenges Professional guidance e.g NMC Links across the interfaces – e.g primary care and acute care Ward planning and ward rounds e.g meetings lasting 3 hours O Patient experience – patient stories Incident reviews – formal reporting mechanisms Junior doctor/Nursing education in relation to medicines Reporting structures e.g Safety, Governance and Risk group 1st level Identifying improvements..
- 23. Medication Errors Past Harm Reliability Sensitivity to Operations Anticipation and Preparedness Integration and learning Administration errors [ M] • Omissions • Wrong dose • Wrong medicine • Wrong time • Wrong route • Wrong patient Patient experience – e.g. adverse reaction to medication [M] Standardised process • Start time/format • Checking/rechecking process • Attending to emergencies Shift planning and delegation of roles Response to patient queries Having to chase up patients to get their medication / Not all patients come to trolley for medication Complying with medicines reconciliation Prescribing Errors - Zero Tolerance Criteria [M] Unable to read prescription Awaiting for medication changes to occur to dispense Staff knowledge of patients [measure-monitoring] Staff knowledge/confidence Dealing with competing priorities on the ward to protect the drug round Interruptions from pharmacist, doctor or domestic [ M] Conversations with patients, what information do they need and want about what to expect? (Ward Board & leaflets) Get hold of Doctor to make TPAR changes Shift planning (Reliability as well as S.T.O.) - decide males/females - breaks planned better - structure for breakfast group, domestic staff, etc. Staffing levels [M] Safety briefing – previous errors (M) Delegation of known tasks at the beginning of the shift Well organised drug dispensary/trolley How we do this rather than measure it Sharing good practice/poor practice Learning from previous errors Datix reviews/verifiers Culture of reporting near misses Patient learning/responsibility positive risk taking/recovery/self management Patient knowledge of Medication and side effects Patient self dispensing Outcome/Learning Top Tips •Involve Everyone •Pick a date and get started. •Bottom Up approach
- 24. 26 Our approach film NHS Tayside - Alison McGurk https://www.youtube.com/watch?v=7IAzMDv56Bo
- 25. Reflect on what you have heard from our story
- 26. 28
- 27. Take a deep dive in to your projects using the framework
- 28. Dr. Jonathan Kirk Key learnings relative to the frontline implementation of the Vincent framework in Scotland
- 29. 31 Some reflections….. Dr Jonathan Kirk, National clinical lead Healthcare Improvement Scotland @JonathanKirk42 e: [email protected]
- 30. 32 ‘Not every change results in an improvement’ Reflection 1
- 32. Reflection 3
- 33. 35 Reflection 3b If I was to walk across a road blindfolded I might be lucky and make it to the other side. However, if I kept repeating it, sooner or later it would likely end badly
- 35. 37 Reflection 5
- 36. decision noun a choice that you make about something after thinking about several possibilities
- 37. 39
- 39. Organisation Past Harm Reliability Sensitivity to Operations Anticipation and Preparedness Integration and learning Group Past Harm Reliability Sensitivity to Operations Anticipation and Preparedness Integration and learning Group Past Harm Reliability Sensitivity to Operations Anticipati on and Prepared ness Integration and learning Individual Individual IndividualIndividual Individual
- 41. 43
- 42. Dr. Ross Baker How the framework can be used within the Canadian Healthcare Context
- 44. Poll
- 45. Learn more, access Call Recording and CPSI Contacts To learn more about the framework http://www.patientsafetyinstitute.ca/en/toolsResources/Measure-Patient- Safety/Pages/default.aspx To access the slides and recording of the call (available in about 5-7 days) http://www.patientsafetyinstitute.ca/en/Events/Pages/Implementing-the-Vincent- Framework-at-the-Frontline.aspx To learn more about SHIFT to Safety http://www.patientsafetyinstitute.ca/en/About/Programs/shift-to- safety/Pages/provider.aspx CPSI contacts Virginia Flintoft [email protected] 416-946-8350 Anne MacLaurin [email protected] 902-315-3877