11 th April 2014, National GTT Workshop Penny Pere, Service - PowerPoint PPT Presentation

  11 th April 2014, National GTT Workshop

Penny Pere, Service Improvement Manager, GTT Coordinator John Gommans, Chief Medical Officer, Programme Sponsor David Gardner, Physician Ben Robertson, Pharmacist Barb Ryan, Quality & Risk Coordinator Sue Sinclair, Clinical Audit Coordinator Mike Connolly, CNS Mental Health Janine Palmer, CNS Renal Alison Wallis, CNS Orthopaedics

 354 files reviewed over 18 month period  160 adverse events  5 severe events – categories G, H and I  33 adverse events prior to admission

AE /1000 beddays 100.0 150.0 200.0 250.0 300.0 350.0 50.0 0.0 4 (early Sep 12) 5 (late Sep 12) 6 (early Oct 12) 7 (late Oct 12) 8 (early Nov 12) Adverse Events / 1000 beddays (Cycles 1 - 28) 9 (late Nov 12) 10 (early Dec 12) 11 (late Dec 12) 12 (early Jan 13) Cycle - Cycle Start Date 13 (late Jan 13) 14 (early Feb 13) 15 (late Feb 13) 16 (early Mar 13) 17 (late Mar 13) AE / 1000 beddays 18 (early Apr 13) 19 (late Apr 13) 20 (early May 13) 21 (late May 13) 22 (early Jun 13) 23 (late Jun 13) 24 (early Jul 13) 25 (late Jul 13) 26 (early Aug 13) 27 (late Aug 13) 28 (early Sep 13)

Adverse Events / 1000 beddays: Q1 (Jul-Sep 12) - Q6 (Oct-Dec 13) 120.0 AE /1000 beddays 100.0 80.0 60.0 40.0 20.0 0.0 Q1 (Jul- Q3 (Jan- Q5 (Jul- Sep 12) Q2 (Oct- Q4 (Apr- Sep 13) Q6 (Oct- Dec 12) Mar 13) Jun 13) Dec 13) Quarter

Admissions with AE 100.0% 120.0% 20.0% 40.0% 60.0% 80.0% 0.0% 4 (early Sep 12) 5 (late Sep 12) 6 (early Oct 12) 7 (late Oct 12) 8 (early Nov 12) Admissions with Adverse Events (Cycles 1 - 28) 9 (late Nov 12) 10 (early Dec 12) 11 (late Dec 12) 12 (early Jan 13) Cycle - Cycle Start Date Admissions with AE 13 (late Jan 13) 14 (early Feb 13) 15 (late Feb 13) 16 (early Mar 13) 17 (late Mar 13) 18 (early Apr 13) 19 (late Apr 13) 20 (early May 13) 21 (late May 13) Lower CI 22 (early Jun 13) 23 (late Jun 13) 24 (early Jul 13) 25 (late Jul 13) 26 (early Aug 13) 27 (late Aug 13) Upper CI 28 (early Sep 13)

Admissions with Adverse Events: Q1 (Jul-Sep 12) - Q6 (Oct-Dec 13) 70.0% Admissions with AE 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Q1 (Jul- Q3 (Jan- Q5 (Jul- Sep 12) Q2 (Oct- Q4 (Apr- Sep 13) Q6 (Oct- Dec 12) Mar 13) Jun 13) Dec 13) Quarter

Cy Cycle cle 1 t 1 to 36 (lat 36 (late e Jul 12 t Jul 12 to early early Jan 1 Jan 14) Harm Cat Harm Categor gory Adverse Ev rse Events ents % t % total tal Medication/IV Fluids 56 35% Patient Care 27 17% Hospital Acquired Infection 38 24% Surgery or Other Procedure 37 23% Other 2 1% To Total 160

Cy Cycle cle 1 t 1 to 36 (lat 36 (late Jul e Jul 12 t 12 to early early Jan Jan 14) Medicatio Medication/ IV Fluid / IV Fluid Sub-Harm Sub-Harm Cat Categor gory Adverse Ev e Events ents % t % total tal IV Volume overload/electrolyte imbalance 3 5% Cardiac event/arrhythmia 3 5% Renal insufficiency 1 2% Allergic reaction 6 11% Bleeding 7 12% Delirium/confusion/over-sedation 12 21% Diarrhoea 4 7% Glycaemic events 0 0% Hypotension 4 7% Nausea and vomiting 9 16% Constipation 4 7% C. Dificile Infection 0 0% Other 3 5% To Total 56

Age Gender Diagnosis Drug Adverse Event Department 61 f #NOF Opiates Delirium/Confusion/Over-sedation Ortho 34 f abdo pain Opiates Nausea/Vomiting Gynae 85 f abdo pain Opiates Nausea/Vomiting Surgical 92 f vertebral # Opiates Constipation Medical 77 f pseudogout Opiates Delirium/Confusion/Over-sedation Medical 19 m leg # Morphine Nausea/Vomiting Ortho 82 f TKR Morphine Hallucinations Ortho 58 f vertebral # Opiates Constipation Ortho 72 f #NOF Opioids Oversedation Ortho 72 m TKR Opiates Delirium/Confusion/Over-sedation Ortho 68 m TKR Opiates Allergic reaction Ortho 47 m pilonidal abscess Opiates Nausea/Vomiting Ortho 55 m renal colic Opiates Low BP Urology 76 f #NOF Opiates Delirium/Confusion/Over-sedation Ortho 78 f THR Opiates Delirium/Confusion/Over-sedation Ortho 57 f metastatic RCC Opiates Delirium/Confusion/Over-sedation Ortho 85 f fall Opiates Sedation Medical 71 m THR Opiates Nausea/Vomiting Ortho 76 m reduced mobility Opiates Nausea/Vomiting Medical 76 f #NOF Opiates Constipation Ortho 75 f fall Tramadol Caused fall Medical 84 m elective surgery Tramadol Nausea/Vomiting Ortho

Cy Cycle 1 t cle 1 to 36 (lat 36 (late Jul 12 t e Jul 12 to early Jan 1 early Jan 14) Patient Care Sub-Harm Cat Patient Care Sub-Harm Categor gory Adverse Ev e Events ents DVT/VTE 1 Fall with no injury (observation only) 3 Fall with injury 5 Pressure injury 6 Skin tear, abrasion or other breakdown 7 Other 3 To Total 25

Cy Cycle cle 1 t 1 to 36 (lat 36 (late e Jul 12 t Jul 12 to early Jan 1 early Jan 14) Hospital A Hospital Acquired Inf ired Infection Sub-Harm Cat ction Sub-Harm Categor gory Adverse Ev e Events ents % % total tal Catheter associated UTI 8 21% Central line associated bloodstream infection 1 3% Respiratory infection (non-ventilator) 7 18% Ventilator associated pneumonia 1 3% Surgical infection 14 37% MRSA 1 3% VRE 0 0% Clostridium difficile 0 0% Candida Infection 1 3% Peripheral or CV line non bloodstream infection 3 8% Other 2 5% To Total 38

Cy Cycle 1 t cle 1 to 36 (lat 36 (late Jul 12 t e Jul 12 to early Jan 1 early Jan 14) Surger Surgery and Pr and Procedu ocedure Sub-H e Sub-Harm Cat rm Categor gory Advers rse Ev e Event ents % t % total tal Abnormal bleeding 5 14% Blood clots and other occlusions 4 11% Cardiac complications 2 6% Complications due to peripheral venous access 3 9% Complications due to arterial access/puncture 1 3% Hypotension 0 0% Acute renal failure 0 0% Respiratory complications 2 6% Post-op ileus 1 3% Radiation related injury 0 0% Removal, repair or injury of organ 3 9% Complications related to percutaneous access 0 0% Other 14 40% To Total 35

Cy Cycle cle 1 t 1 to 36 (lat 36 (late e Jul 12 t Jul 12 to early Jan 1 early Jan 14) Se Severity rity Count Count E: Temporary harm requiring intervention 93 56% F: Temporary harm requiring initial or prolonged hospitalization 69 41% G: Permanent harm 1 1% H: Intervention required to sustain life 3 2% I: death 1 1% To Total 167

1. Category G Necrotic/infected laparotomy wound 2. Category H Re-intubation in ICU 3. Category H Respiratory arrest post-op 4. Category H Oversedation with morphine requiring naloxone 5. Category I Hospital acquired pneumonia

Harm rm C Category ry Ad Adverse rse E Events On A Admissi ssion GP Other H Hosp spital al Rest st H Home Dial alysis Other Medication/IV Fluids 56 11 5 0 1 0 1 27 Patient Care 7 0 0 5 0 2 Hospital Infection 38 10 2 4 1 0 0 Surgery/Procedure 37 3 0 3 0 1 0 Other 2 2 0 1 1 0 0 To Total 160 33 7 8 8 1 3

Issues with External Location Data  Events labelled as present on admission not always categorised as external sites when should have been  2 events did not have harm categories recorded  Should all medication related events present on admission be attributed to the GP?