Undertaking root cause analysis

Dr. Peter Woodhouse,Chair, Thrombosis & Thromboprophylaxis Committee,Norfolk & Norwich University Hospital.

•~1010 beds•~70,000 adult discharges / year•~70,000 adult day cases / year

VTE prevention programme

•Comprehensive local clinical guidelines•Drug chart Thrombosis Risk Assessment (TRA)•Monthly audit of TRA completion, all adult wards•HAT root cause analysis

•Deaths since Jan 2009•Non-fatal since Sept 2009

•Monthly ‘HAT report’ published Trustwide•Patient information•Link Nurses•‘Click for Clots’ intranet site

Thrombosis Risk Assessment (TRA) completion (ward audit)

37 39 42 46

7585 89 94 95 93 92 97 95 96 97

63 61 58 54

2515 11 6 5 7 8 3 5 4 3

0102030405060708090

100O

ct-0

9

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

Apr-

10

May

-10

Jun-

10

Jul-1

0

Aug-

10

Sep-

10

Oct

-10

Nov

-10

Dec

-10

% TRA not completed

TRA completed

HAT Root Cause Analysis (RCA)Why do it?

• To find out why it happened• To find out if it could have been avoided• To find lessons to be learnt

• To motivate / engage fellow clinicians– We had seen it work before for C.Difficile

What’s a HAT?

• Hospital Acquired (or Associated) Thrombosis– DVT or PE during hospital admission

• What about those who probably had DVT / PE on admission but not initially suspected?

– DVT or PE within 90 days of discharge• We initially chose ‘within 30 days’ (until April 2010)

How did we find the HATs?

• Non-fatal– Inpatient anticoagulation (warfarin dosing) service– DVT clinic

• Fatal– Pathology Liaison & Bereavement Nurse

• Death certificates• PM reports (including Coroner’s)

Root Cause Analysis

•Case reviewed and sections 1 to 3 completed by member(s) of T&T team. •Partially completed form sent to Consultant responsible for index admission to complete Section 4•Completed RCA form returned to T&T team, data collated and entered onto database.•Common themes identified•Summary results contribute to monthly HAT report

Root Cause Analysis

•Case reviewed and sections 1 to 3 completed by member(s) of T&T team. •Partially completed form sent to Consultant responsible for index admission to complete Section 4•Completed RCA form returned to T&T team, data collated and entered onto database.•Common themes identified•Summary results contribute to monthly HAT report

Root Cause Analysis

•Case reviewed and sections 1 to 3 completed by member(s) of T&T team. •Partially completed form sent to Consultant responsible for index admission to complete Section 4•Completed RCA form returned to T&T team, data collated and entered onto database.•Common themes identified•Summary results contribute to monthly HAT report

• 162 HATs per annum (2010)– 125 non-fatal (62 PE / 63 DVT)– 37 fatal (31 PE / 6 DVT)

• ~ 2 / 1000 inpatient episodes• Location of VTE diagnosis

– 46% index admission– 36% readmission– 18% outpatient / community

HAT deaths 2009-2010

HAT Deaths <30 days post-discharge

• 2009–Total 36

• 30 PE• 6 DVT

• 2010–Total 31

• 31 PE• 0 DVT

• Further 6 PEs, 30-90 days

Non-fatal HAT 2009-2010

HAT by age & gender

Deaths (n=73)

• Mean age 78 years

• 51% male• 49% female

• 86% emergency• 14% elective

Non-fatal (n=165)

• Mean age 66 years

• 45% male• 55% female

• 63% emergency• 37% elective

HAT by Specialty

Deaths (n=73) Non-fatal (n=165)

HAT by Predominant diagnosis

Deaths (n=73) Non-fatal (n=165)

Risk assessment and prophylaxis in HAT cases

Compliance with NICE CG92

Root cause of HAT

Problems identified and tackled along the way

• Failure to risk assess– Education campaign, drug chart risk assessment

• Delay in first dose of LMWH– ‘Thromboprophylaxis round’ in the evening on orthopaedic

wards

• Unexplained gaps in LMWH prophylaxis– Targeted audit

• Inappropriately Low-dose LMWH– Tinzaparin 3500 units removed from stock– Education re. correct dosing in renal impairment

Problems identified and tackled along the way

• Delay in diagnosis and treatment of VTE– Education

• Failure to prescribe according to the risk assessment– Audit and feedback, re-design drug chart TRA

• Some VTE events seem to be unpreventable– Maintain morale and commitment to VTE prevention

Using the results of RCA

Hospital Associated Thrombosis (HAT) Monthly Report

December 2010

Liz Lorie, Specialist Nurse,Nicola Korn, Specialist PharmacistHamish Lyall, HaematologistJennie Wimperis, HaematologistPeter Woodhouse, Chair, T&T Committee

Trust intranet site•Links to local and national guidelines•‘HAT reports’ / audit reports•Treatment protocols•Patient information•Adverse incident reporting

•‘Blog for bleeding’•Feedback to anticoagulation service and T&T team

Resources required•Specialist Pharmacist•Specialist Nurse(s)•Pathology Liaison Nurse•Two Haematologists•Geriatrician•Head of Pharmacy•IT Web Specialist•Supportive management

Any questions?