Excellence Through Design—improving the Massive Haemorrhage Protocol

Abstract

Objectives & BackgroundThere has been an increasing use of massive haemorrhage protocols (MHP) within our trust. A number of clinical incidents were noted around roles/responsibilities when MHPs were run. Design failures (latent errors) were felt to contribute to these. Most MHPs are untested and are reliant on clear protocols, good communication and efficient team work. We proposed that running drills of our MHP in the ED setting would allow us to identify the latent errors and human factors that exist in our MHP then addressing these.MethodsWe proposed a 2 stage process where initially we tested functionality then identified and changed aspects of the system.FunctionalityWe ran 5 in-situ, real time MHP simulations involving the relevant members of the MDT in the ED. The 20 minute scenarios were followed by a structured human factors debrief. This allowed us to establish latent errors that were affecting the MHP. Results were then collated and codified from the sessions to allow planning of teaching for ED and non-ED staff.RedesignFollowing this a card redesign was identified as being necessary. We used the principles of negative space, contrast, proximity and the pictorial superiority effect. A cluster randomised recall trial was then conducted at an F2 teaching session (66 participants), with participants blinded to the other version of the cards. A trauma video was shown (thoracotomy) and recall measured after this. Data analysed by an author blinded to both the study design and the data collection. GAfREC permission given by R+D.ResultsHF/Ergonomics phase1. Difficulty identifying team members/roles2. Communication difficulties-same task being undertaken by multiple staff members3. Notes/ID labels not given to trauma team leader (TTL). TTL felt to be unapproachable4. Porters not feeling able to identify themselves5. Action cards and protocol not used-text heavy6. Staff not realising action cards were double sided7. Blood forms unavailable8. Poor prioritisation/labelling of the crossmatch sample9. Pre-arrival preparation steps being omittedCard redesign phase18 people recalled all the important information – all used the new cards. 0 people in the old card group recalled all the information. 66 of the f2s (100%) preferred new design of card.ConclusionHF principles helped identify areas for improvement. Utilising design principles appears to have had significant impact on the effectiveness of the cards.

Translational simulation revisited: an evolving conceptual model for the contribution of simulation to healthcare quality and safety

“…For example, training nurses on the dangers of rapid intravenous potassium administration may not be enough to reduce adverse events until concentrated potassium ampoules are removed from wards and replaced with 500 ml bags of diluted potassium [ 6 ]. Knowing which blood products are required for a trauma patient will not be enough if there are ineffective systems for ordering and delivering those blood products to the trauma bay [ 7 , 8 ]. Teaching healthcare practitioners to ‘speak up for safety’ will be ineffective if toxic hierarchies and cultural norms go unaddressed in healthcare environments [ 9 ].…”