Transitioning Patients Between

BC Cancer Agency & Vancouver – Acute Services

Quality Forum

February 28, 2013

Sue Fuller BlameyDarren Kopetsky

Lorraine Blackburn

Case for Change

Patient Safety Event with a patient transferred from Vancouver General Hospital (VGH) to BC Cancer Agency for an out-patient Radiation Therapy appointment

Collaboration between BC Cancer Agency and Vancouver General Hospital

•Met with leaders, educators, physicians & front- line staff from both Hospitals•Reviewed transfer process between organizations

Review of Transition Processes

• Realized that the process was really complex with many possible ways for the process to fail•Conducted a Failure Modes Effects Analysis (FMEA) to identify defective process steps and mistake-proof the process•Listed the top 12 ways that the process could fail

Transfer Failure Modes

1. Lack of Communication about patient needs

2. Lack of pain management plan prior to transfer

3. Nurse unaware of care plan4. No medication with transfer5. Unclear physician’s orders6. No 7 rights of medication

administration

7. No after-hours policy for retrieving medication at BCCA8. Nurse uneducated about BCCA RT protocol9. No policy for VCH nurse to give medications at BCCA10. VCH nurse unaware of BCCA procedure for radiation therapy11. No communication back to sending hospital from BCCA12. No physician follow-up post- procedure

Reviewed Reasons for Failure Modes

Failure Modes Analysis Worksheet

Analysis of Failure Modes

•Listing the root causes•Scoring severity and probability of recurrence•Identifying solutions to mistake-proof the root causes/failures

Recommendations/Solutions

1. Staff at VGH and BCCA need to communicate verbally and in writing prior to patient transfer

2. VGH staff to contact physician prior to transfer if patient condition changes

3. VGH staff education re: RadiationTherapy procedure

4. Discussion at BCCA MAC re: appropriate use of verbal orders

5. Patient requires pain management plan prior to transfer

Created Checklists for BCCA and Vancouver – Acute Services Hospitals

Created Checklists for BCCA and Vancouver – Acute Services Hospitals

•

Clinical Practice Document Vancouver – Acute Services

07/21/11

Recommendations/Solutions

6. Create intra-facility policy on ability for VGH nurses to give medications at BCCA & after- hours medication procurement at BCCA

7. Education re: 7 rights of medication administration

8. Protocols for giving medication after-hours at BCCA

Recommendations/Solutions

9. BCCA Communication back to sending facilities10. PHSA Handovers Framework

Further Work on Handovers & Transitions in Both Organizations

PHSA: Handovers and Transitions FrameworkAddresses three types of hand-offs (Internal, External, Intra- agency/health authority).•Each PHSA agency or service must include in their processes and procedures the following core elements:

a)Standard mechanism of transferb)Patient/Caregiver involvementc)Interactive communicationd)Comprehensive informatione)Review of previous historyf)Documentationg)Ensure minimal interruptions

Further Work on Handovers & Transitions in Both Organizations

Vancouver – Acute Services

•Clinical Practice Document on Transfer of Patients for Tests/Procedures: Patient Accompaniment

• expands use of checklist beyond BCCA

• identifies when accompaniment is required, and what to consider when using clinical judgment to establish requirements in other scenarios.

Reporting, Measuring & Evaluation

Number of BCCA Transition Events

0

5

10

15

20

25

30

Nov Jan

Mar

may Jul

Sep Nov Jan

Mar

May Jul

Sep Nov

Month

# of

eve

nts

# of transition events

Next Steps – Roll out to other Health Authorities

•Transfer Checklist rolled out to Fraser Health – Abbotsford & Surrey•Plans to invite all other Health Authorities to roll out process

Key Learnings

• Need to collaborate with key stakeholders to get to the bottom of all root causes of the failures in a process

• Need to understand each other’s process in order to make adjustments to prevent errors

• Need to regularly communicate even after project implementation

• Re-implementation of education and procedures is a constant issue

Thank you to Participants in this Process

Dr. James MorrisLise BelangerDr. Peter LimDr. Ryan CarlsonBrendan TomkinsFrankie Goodwin

Janice DirksenKaren JanesLorraine BlackburnDarren KopetskySue Fuller Blamey

07/21/11

Questions?