Update April 18

At the last meeting we reviewed our recent activity. We noted the massive progress that had been made with regard to reducing the incidence of CLABSI and also the landmark achievement of reaching a first stage of agreement regarding drug infusion concentrations for paediatric patients. We reviewed the progress made in a number of other areas and noted that the strength of MiST came for the collaborative energy and discussion. We discussed our existing model, based on the Solutions for Patient Safety, work in the US, and concluded the focus on data was not useful in all of the areas in which we share an interest. In fact, some units were struggling to identify the resource to submit such data. Therefore, we agreed to refocus our goals, only seeking to gather and collate data where discussion and examination of such might enable us to better understand the risks and safety issues as a vehicle to identifying methods to reduce them. Our exploration of medication errors through the use of MERP scoring would be an example of this. The mission statement on the home page of the website has been updated to reflect this.

We discussed two main areas at the last meeting: Paediatric Tack and Trigger systems and progression of the infusion standardisation work. The former identified the need for basic provision of good education and standards regarding the conduct of observations and also the need for a standardised “language” to communicate the severity of illness that is agnostic to local scoring and applicable to context. For example, a “severely unwell” child (a child scoring “red”), when reviewed in a GP surgery and referred to a local hospital would be exhibiting different physiology to a child on a tertiary cardiology ward referred to PICU, but would share a similar urgency for review/escalation to the next tier up of clinical service. The conclusions from this discussion were fed into an inaugural “PEWS board” meeting, hosted by the RCPCH in February. A work program will shortly be published from this meeting which we will share through the MiST network.

Our discussions regarding drug infusion standardisation identified the need for provision of a toolkit to assist organisations in adopting these standards. We will be looking to turn over our autumn meeting to this task but would like to convene a teleconference before then to discuss our strategy in more detail. We are very keen to involve all interested individuals in this discussion (MiST members or not). Please email Peter-Marc directly (chair [at] mist-collaborative [dot] net) if you are interested or would like to nominate someone to join this teleconference; please include relevant contact details AND complete this Doodle poll to identify a suitable time for all:  https://doodle.com/poll/duvumfgp99rancr4

We will shortly have details for the times and locations of our meetings later this year. We will circulate these as soon as available. Both Medication Incidents and Caring for the Careers will be on the agenda of these upcoming meetings.

Finally, we noted that the discussion forum on the website had not received many visitors (or entries). This was added to provide an ongoing outlet for the enormous energy experienced at each and every of our face to face meetings. It may just be that the on-line environment does not promote the same enthusiasm, but if you have any ideas for how this area should be restructured or administered we would welcome your feedback; if someone would like to run and promote the forum that would be even better! Please email Peter-Marc directly with your thoughts.

Peter-Marc Fortune