IHI Forum

I am attending the annual IHI forum, in Orlando far away from the arctic conditions at home. Amazing stuff,  spending the day at a course devoted to paediatric patient safety, with talks from the worlds experts in this area. Steve Muething, Cincinnati Children's talks about developing a high reliability organization in healthcare. Matt Scanlon, Milwaukee, talks about human factors and measurements in paediatric safety. Anne Matlow, Sick kids Toronto talks about the major problem of diagnostic error in children, pointing out that diagnostic mistakes account for 13-20% of adverse events, but are more likely to be preventable and are more likely to cause serious harm or death. Paul Sharek, Stanford discussed medication safety, raising the provocative point that although a great deal of money has been devoted to improving medication safety,  medication errors account for 20% of all errors and a much smaller proportion of serous harm.

Trigger Tools

How should we measure the harm we cause in healthcare? One method, increasingly widely used, is a trigger tool. These are standardized and validated instruments with which one reviews a random selection of medical charts; when a "trigger" is identified that might signal a possible harmful occurrence, the chart is reviewed in more detail to determine whether harm did occur. There are two benefits; an organisation can measure the harm it is causing over time and take steps to reduce the harm, and second, measure its effectiveness in reducing harm over time. In contrast to conventional incident reporting, the rate of harm detected by these tools is 2-5 fold higher. For more reading, I would suggest the following; IHI and NHSIII

IHI Model for Improvement

Am attending and speaking at a forum hosted by HSE and Clinical Indemnity Scheme which is discussing the Heartbeat Scheme. Apart from the specific cardiovascular theme, Noeleen Devaney, a former IHI fellow is discussing the IHI Model for Improvement. She makes the critical point that this methodology can be applied to any problem in healthcare, clinical and non-clinical. Such an approach is critical to empowering front line staff, improving quality, and improving work satisfaction. For more information I would suggest checking out this section of the IHI website.