Cambios en el proceso de asignación de recursos

The surgical ward-round process was mapped based on observation of clinical practice for around 20 hours. This included observation in general surgery (n=10), vascular surgery (n=2), cardiothoracics (n=2), urology (n=3), intensive care (n=2) and medical (n=1)(surgical-outlier) wards.

Mapping of the ward round process was carried out after observation of clinical practice (Figure 5.1). The map was de-constructed into three steps based on the daily practice i.e. discussion prior to reviewing the patient (pre-patient hand-over); patient review (bedside exchange of information), and discussion after the patient review (post-patient review discussion).

Based on observation of the practice and the mapping of the whole process, a failure mode task-list was created (Table 5.1) which was scored based on established and previously validated ‘FMEA Scoring Sheet’ (Figure 5.2). Hazard scores were calculated by multiplying severity, frequency and detectibility scores. The group also

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decided whether each failure mode was a single point weakness and if there was a control measure in place to prevent the failure mode.

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Table 5.1 – Failure mode list developed after observation and mapping of the ward-round process and scored using FMEA Score sheet (Figure 5.2)

WARD ROUND FMEA

No. Process step

Definition Failure mode Effects

Sever it y Frequency Det ec tabi li ty Singl e poi n t C ontr ol H aza rd Score 1 Patients prioritized

Decisions are made regarding which patients should be seen first based on medical urgency, or which patients are conveniently located. (i.e. Patients on the home ward first)

Not prioritised Original patient prioritised list not followed 4 4 2 n y 32 2 Prioritisation incorrect 4 4 1 y n 16 3 Team uses lifts/stairs/common areas to change wards

Team uses lifts/stairs/common areas to change wards Do not wash hands Transmit infections 4 4 2 n n 32

4 Discuss patient

details

Confidentiality compromised

4 2 4 n y 32

5 Team goes to wrong

place

Ward round delayed 4 4 3 y n 48

6 Team sees the first or the next patient

The team move towards the first/next patient on the list after entering the ward area.

Team is incomplete Patient care suboptimal

4 4 2 y n 32

7 Team goes to wrong

patient

Incorrect treatment 4 3 3 y n 36

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9 Open curtain/door to patient bed space

The team pull open the curtain or open the door to the side room

Team does not 'knock'

Patient embarrassed 2 4 1 n n 8

10 Do not wash hands Transmit infection 4 4 2 n n 32

11 Close curtain/door to patient bed space

The team close the curtain or open the door to the side room

Not closed Confidentiality breached

2 4 3 n n 24

12 Team introduces themselves

Team members introduce their full name and role to the patient

Team does not introduce themselves

Patient cannot tell the doctors that they have come to see the wrong patient

4 4 3 y n 38

13 Team checks Patient's identity

Team members ask the patient to confirm their identity, or take other appropriate measures to confirm e.g. read identity bracelet

Team does not check Patient's identity

Incorrect Patient treatment

4 3 3 y n 36

14 Team takes Patient’s history

A history is obtained from the patient. Do not take accurate history

Incorrect Patient management

4 4 3 n n 48

15 Observation charts/fluid charts/catheter and drain output checked

Observation chart results (e.g. respiratory rate, heart rate) and results are checked and/or updated.

Charts not checked correctly

Complication missed 4 4 1 y n 16

16 Team examines Patient Patient is given a physical examination Examination not done correctly

Incorrect Patient management

4 4 1 y n 16

17 Team checks Patient is wearing TED stockings

If the patient has been issued TED stockings, are they wearing them at all or correctly?

Team does not check Patient at increased risk of

thromboembolism

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18 Communication with nurse/physio/dietician etc

Communication between doctors

andnurses/physiotherapists/dieticians etc. Inadequate communication Patient care suboptimal 4 4 1 y n 16

19 Blood results checked Blood results checked Blood results not

checked correctly

Patient care suboptimal

4 4 3 y n 48

20 Imaging results checked Imaging results checked Imaging results not checked correctly

Patient care suboptimal

4 4 3 y n 48

21 Drug chart checked Drug chart checked Drug chart not

checked correctly

Patient care suboptimal

4 4 2 y y 32

22 Team teaching occurs Senior doctors teach other doctors and medical students Team teaching does not occur

Team does not fully understand how to manage the Patients

4 4 1 y y 16

23 Nutrition status checked The patient’s nutritional status is assessed based on how the patient reports their eating, or by measuring

parenteral/enteral nutrition

Nutrition status not checked Patient malnourishment untreated 4 4 4 y n 64 24 Differential diagnosis considered

A list of differential diagnoses are proposed and discussed by members of the team

Differential diagnosis not considered

Incorrect diagnosis 4 4 3 y n 24

25 Prognosis discussed with the Team and Patient

Patient prognosis is discussed amongst members of the team and with the patient

Prognosis not discussed with the Team and Patient

Inappropriate Patient management

4 3 2 y n 24

26 Wounds checked Surgical wounds are assessed for infection and healing Wounds not checked correctly

Wound infection missed, treatment delayed

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27 Drains checked Chest and other drains are checked Abnormal drain output not checked correctly

Complication missed, treatment delayed

4 3 1 y y 16

28 Lines checked Intravenous and other lines are checked Lines not checked Line infection missed, treatment delayed

4 4 1 y y 16

29 Arrange communication with the relatives

If necessary, the patient’s relatives are contacted. Communication with relatives not arranged correctly Inadequate communication 4 4 2 y n 32 30 Discussions regarding appropriate investigations

Team discuss which investigations are most appropriate in terms of urgency, radiation, cost etc.

Not discussed correctly

Inappropriate investigations

4 4 2 y y 32

31 Discharge planning If patient is ready or awaiting discharge, details of discharge should be prepared

Incorrect discharge planning

Delayed discharge 4 4 1 y n 16

32 Follow-up arranged Arrangements are made to see the patient again at a later time and/or date to check his/her status

Follow up arranged incorrectly

Suboptimal Patient management

4 4 3 y n 48

33 Jobs prioritized Ward jobs are delegated to members of the team (House officers) and prioritized in terms of urgency

Jobs not prioritized correctly

Suboptimal Patient management

4 4 2 y n 32

34 Notes updated Patient notes are updated with latest results and management plans

Notes not updated correctly

Treatment delayed 4 4 2 y n 32

35 Handover sheet updated Handover patient list is updated with new information about the patients

Handover sheet not updated correctly

Suboptimal Patient management/Incorrect

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treatment 36 Team checks that there

are no remaining issues

Team checks that there are no remaining patients to be seen or other tasks to delegate or perform

Team does not check that there are no remaining issues

Suboptimal Patient management

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