how to approach clinical governance for epma implicated issues · 2019-04-11 · unacceptable risk?...

How to Approach Clinical Governance for ePMAImplicated Issues

The eMeds Decision Tree

Background to Trust

• 3 Hospital Sites

• 8,000 users

• MedChart – early

adoptor ward May 19

• Rapid rollout across

site.

My Digital Future

Did the depart from agreed eMedsTraining?

If yes into box answer: were resources, protocols, or procedures safe workable intelligible, correct and in routine use? If no into box go straight to no out of box.

The eMeds Decision TreeSubstitution TestFunctional TesteMeds TestIncapacity TestDeliberate Harm Test

Did the system function as expected by the manager?

Did the individual depart from agreed clinical protocols or safe procedures?

Is there evidence that the individual took an unacceptable risk?

Were there significant mitigating circumstances?

Were the actions as intended?

Does there appear to be evidence of ill health or substance abuse?

Were resources available to the individual to guide and support the use of eMeds?

Would another individual coming from the same professional group possessing comparable qualifications and experience act in the same way in similar circumstances?

Were there any deficiencies in clinical training, experience or supervision?

Were adverse consequences intended?

Known medical condition?

As per Just Culture Guidance




Ethos of eMeds Incident Decision Tree

Ethos

• Support the Just Culture

Guide on which it is

based;

• Understanding – eMeds

involvement

• Mitigation of Clinical

responsibilities

• Appropriate and

Consistent actions.

To Remember

• Decrease likelihood of an

error – unlikely to

completely prevent

• cannot completely defer

their professional

judgement to eMeds.

As such it is very rare that a medication incident can be categorised into wholly a clinical or EPMA incident.

Applicable unchanged

?Could eMeds aid prevention in future

Add in eMeds thoughts

Maintain link with Clinical aspects of incident


How the individual used system

Did the system work as expected

The foresight test If intent to harm and incapacity have been discounted, the foresight test examines whether protocols and safe working practices were adhered to. Our preliminary findings indicate the majority of patient safety incidents involve protocol violation - The Incident Decision Tree: Guidelines for Action Following

Patient Safety Incidents

The foresight test If intent to harm and incapacity have been discounted, the foresight test examines whether protocols and safe working practices were adhered to. Our preliminary findings indicate the majority of patient safety incidents involve protocol violation - The Incident Decision Tree: Guidelines for Action Following

Patient Safety Incidents




Training

Did the individual depart from agreed eMeds training?

Resources - eMeds

Were resources available to the individual to guide or support the use of eMeds?NB – Training: IT Systems

viewpoint

User not following training given does not necessarilyconfer any culpability

NB – Training: IT Systems viewpoint

User not following training given does not necessarilyconfer any culpability





System functionalityBack to clinical!

Did the individual depart from agreed clinical protocols or safe procedures

Review so far – Review Similarities

Left with the Tests which are to be amended

Left with the Tests which are to be amended

Review so far – Consider eMeds

eMeds TesteMeds Test Foresight TestForesight Test

Reflect – how individual used system:

Training and Resources

Reflect – how individual used system:

Training and Resources

Reflect – the changes in procedures and

processes and the working of the system

Reflect – the changes in procedures and

processes and the working of the system

Reflect – adherence to training

Reflect – adherence to training


Reflect – Use the system in the manner taught by

official training

Reflect – Use the system in the manner taught by

official training

Reflect – Drug Database, Config or System failureReflect – Drug Database, Config or System failure


Back to clinicalBack to clinical

Were resources available to the individual to guide or support the use of eMeds?

Reflect – Availability and ease of use/accuracy of System resources; user

guides etc.

Reflect – Availability and ease of use/accuracy of System resources; user

guides etc.

Reflect – In all cases refer back to the clinical aspects within original

Decision Tree


Decision Tree

Review so far – Return to Clinical



Decision Tree


Decision Tree

eMEDs DECISION TREE

eMeds TesteMeds Test


Were resources available to the individual to guide or support the use of eMeds?


Review so far – Return to Clinical


eMEDs DECISION TREE

Foresight TestForesight Test


Did the individual depart from agreed clinical protocols or agreed procedures?




Substitution TestFunctional TesteMeds TestIncapacity TestDeliberate Harm Test





Were the actions as intended?

Does there appear to be evidence of ill health or substance abuse?




Were adverse consequences intended?

Known medical condition?





An Example - Gentamycin



Substitution TestFunctional TesteMeds Test








Prescriber wished to create a single stat dose of Gentamycin. Used the system by creating a regular prescription with a note attached to only administer once. The Gentamycin was given 3 times before the incorrect prescription was noticed

Prescriber wished to create a single stat dose of Gentamycin. Used the system by creating a regular prescription with a note attached to only administer once. The Gentamycin was given 3 times before the incorrect prescription was noticed

Yes…the training was to utilise the stat functionality within eMeds

Yes…the training was to utilise the stat functionality within eMeds

NB – asking prescriber to ‘think about’ how to prescribe…

NB – asking prescriber to ‘think about’ how to prescribe…

System view point – we should be developing system to minimise this –lessons learned

System view point – we should be developing system to minimise this –lessons learned

We had provided a number of quick guides inc. stat prescribing and floorwalkers were available

We had provided a number of quick guides inc. stat prescribing and floorwalkers were available

An Example - Ketamine



Substitution TestFunctional TesteMeds Test








Prescriber wished continue patients Ketamine (50mg/5ml) solution on discharge.

Inpt chart – 25mgDischarge summary – 25ml

25ml = 250mg!

Pt unconscious 4/7 –fortunately ok.

Prescriber wished continue patients Ketamine (50mg/5ml) solution on discharge.

Inpt chart – 25mgDischarge summary – 25ml

25ml = 250mg!

Pt unconscious 4/7 –fortunately ok.

No…Prescriber used the discharge system as expected.

No…Prescriber used the discharge system as expected.

System view point – Drug built – ketamine automatically = mlTrust policy to Rx – mg

System view point – Drug built – ketamine automatically = mlTrust policy to Rx – mg

This was reviewed by a number of professionals.

Actions:Clinical – more education

- more knowledge in trust

System – to review all liquid medsTo add line – if

over 80mg (eq. 8ml) request supportive care advice.

This was reviewed by a number of professionals.

Actions:Clinical – more education

- more knowledge in trust

System – to review all liquid medsTo add line – if

over 80mg (eq. 8ml) request supportive care advice.

System Error –review System

Any Questions?

• https://www.ahrq.g

ov/downloads/pub/

advances/vol4/Mea

dows.pdf

how to approach clinical governance for epma implicated issues · 2019-04-11 · unacceptable risk?...

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