ISQUA18-1491Using Point of Care Simulation to Detect Latent Hazards of a Massive Haemorrhage Protocol

Abstract

Objectives: The Royal Free NHS Foundation Trust is updating its Major Haemorrhage Protocol (MHP) in 2018. In order to assess the reliabilty of the MHP a series of high fidelity simulations were carried out across the trust between 08/2017-03/2018. The aim was to identify any latent hazards and potential failure modes along the MHP pathway. Method(s): We delivered high fidelity point of care simulations using a SimMan 3G in five clinical areas around the hospital. The multidisciplinary teams involved all the relevant clinical teams who would routinely be involved in a MHP activation. These included swithboard services, blood transfusion laboratory, clinical haematology, crash teams, PARRT (Patient at Risk and Resuscitation Team)teams, and the clinical team in their clinical areas. The simulations were run for 20-30 minutes as an end-to end scenario where blood units were collected in real time. This was then followed by structured debriefing by two trained simulation debriefers. The pathway was also independently evaluated by another observer using a simplified failure modes & effects analysis (FMEA). This ensured that hazards not recognised by debriefers or participants were also captured. Participating teams were asked for written feedback regarding the simulation training exercise and any further safety issues. Result(s): Latent Hazards & Failure Modes identified were: 1. Delays in recognition of Major Haemorrhage & reluctance to activate MHP. 2. Lack of awareness of the MHP and locating the protocol. 3. Communication failures between clinical staff and blood transfusion laboratory when MHP activated. 4. Failure of team to to assign leadership & team roles. 5. Teams were unaware of nearest source of O negative blood (Blood fridge). 6. Blood samples not taken in a timely fashion leading to delays in processing in laboratory. 7. Fibrinogen levels not being ordered. 8. Tranexamic acid not being stocked on all wards. 9. Expectation of PARRT teams to arrive before resuscitation is started leading to delays in management Multiple changes were made to the overall pathway. Actions taken: 1. Standardised scripts for switchboard operators to ensure that blood bank is contacted when MHP activated. 2. Major Haemorrhage box designed to be standard on Cardiac Arrest Trolley Contents of the Major Haemorrhage Box: - Simplified MHP for wards and remote are use. - Clear signposting of nearest blood fridge - Simplified action cards with roles and clear leadership tasks - Blood sample bottles and prefilled request forms - Tranexamic acid and instructions on administration Further two simulations were carried out to test the functionality of the Major Haemorrhage box. The aim is to roll these out across the trust. Regular point of care simulations are planned in the future to ensure new staff are aware of the MHP and to encourage better team working. Conclusion(s): Human reliabilty analysis methods are routinely used in high risk industries such as nuclear and off shore oil and gas industries to identify and assess possible failure modes in any new design. Its use in healthcare is limited. This project attempts to use a simplified failure modes analysis to provide a structured way to assess how factors such as communication, workload, ergonomic design and decision making affect the major haemorrhage pathway. Anticipating patient safety issues in the design stage will reduce the risks to both patients and clinicians using the MHP.