Prospective risk analysis to
improve continuity of care
after hospital discharge of
paediatric patients
Kaestli LZ,
Cingria L, Babel JF, DeRosso A, Burgnard C, OsiekLecomte P, Grimonet S, Fonzo-Christe C, Bonnabry P
Background & Objectives
Background
‡ Continuity of care at hospital discharge
‡ Particularities of paediatric patients
Objectives
‡ Highlight medication discharge problems
‡ Quantify the risks
‡ Propose strategies
‡ Estimate reduction of risks
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA
Failure Mode Effect and Criticality Analysis
• Prospective risk analysis
Global and shared vision
‡ Quantify risks
‡ Measure the impact of improvement actions
‡ Help prioritize improvement actions
‡ 7 step process
¨ Before prospective study next year with
patients follow-up
‡
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA: steps 1 & 2
1. Definition of multidisciplinary team
(2 hospital & 2 community pharmacists, 1
paediatrician, 1 nurse, 1 mother)
2. Brainstorming Failure modes (FM)
definition answering question « What
could possibly go wrong? »
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA: step 3: Ishikawa diagram
Patient
GP
Community
pharmacist
Hospital
doctor / nurse
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA: step 3: Ishikawa diagram
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA : step 4
4.
Consensual
quotation
for each failure
mode with three
model drugs
(Ibuprofen sirop,
Valganciclovir cpr, Morphine
sol.)
Quotation tables
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA : step 5
‡
‡
•
•
•
Estimation of criticality indexes (CI)
(= « risk priority number »)
Example: Untimely termination of morphine
solution treatment by GP
Occurrence:
Severity:
Detectability:
6
5
3
CI
90
CI(morphine) 90 + CI(ibuprofen) 128 + CI(valganciclovir) 280
3
Î Mean CI = 166
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA: step 5
23 failure modes
5 most critical failure modes:
‡
‡
‡
‡
‡
‡
Criticality index:
Wrong dose prescribed
Untimely stop by patient
Continuing unnecessary ttt
by GP
Wrong schedule
Undergoing dose taken by
patient at home
…
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
205
195
191
185
173
…
FMECA : step 6
8 improvement strategies
One main strategy (applied to 8 most critical FM):
‡ Electronic standardized discharge prescription with
CDSS, compulsory fields, discharge planning etc.
7 additional strategies:
‡ Micro-electromechanical systems for tablets (MEMS)
‡ Phone reminding alert
‡ Hospital treatment protocols available for community
pharmacies
‡ Improvement of patient therapeutic education
‡ Structured transfer-letter or mail for GPs
‡ Administration device (ex: syringe, diary pill-box…)
‡ Hospital pharmacist intervention before discharge
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
FMECA: step 7
‡
Estimation of CI reduction
-77
Actual
-131
-126
-121
-105
100
-167
150
-137
200
-32
250
Electronic prescription
Additional measures
50
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ro
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ro
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g
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es se
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ip
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ve n
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ro
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Pa sto
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e
C
on in t
tt
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ttt
0
‡
Electronic standardized discharge prescription:
total CIP: 39% (8 most critical FM)
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
Conclusion & perspectives
Advantages of FMECA
‡ Simplicity
‡ Global point of view
‡ Help prioritize quality improvement actions
Disadvantages of FMECA
‡ Subjectivity of evaluation
Perspectives
‡ Prospective study with interview of patients and
community pharmacists after hospital discharge
‡ Set up of concrete improvement tools
‡ Measure of impact
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009
Questions ?
L-Z Kaestli - ESCP-GSASA Symposium
Geneva 3-6.10.2009