Safety Incidents and Learning by

The avoidance of unexpected or unintended harm during the provision of healthcare

marisataylorclarke — 2023-08-31 20:35:24 UTC

The NHS England National Patient Safety Strategy (2019), supported by the National Patient Safety Team, sets out a framework to minimise safety incidents and drive improvement in safety and quality. Underpinning the strategy are the foundations of safe cultures and safe systems. Through insight into incidents and systems, with involvement of staff and patients, safety improvement can be made.

Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm

marisataylorclarke — 2023-08-31 20:38:04 UTC

This is a broad definition and clearly includes a wide range of incidents that occur throughout the course of providing care. Reporting and learning principles apply for all incidents regardless of the level of harm. Prevented patient safety incidents (or near misses) can provide the most valuable learning for the NHS because they can flag up problem areas where there is potential for things to go wrong in the future. They can also highlight ways in which either the staff or various controls and defences have prevented the incident harming the patient (or have minimised the harm caused).

How are PSIs reported and monitored?

marisataylorclarke — 2023-08-31 20:40:13 UTC

Every trust has its own structure for identifying, reporting and reviewing incidents. This should be covered at your local trust induction. There are many systems for locally reporting PSIs that may be electronic or paper based. ‘Datix’ is a commonly used system in London.

What happens when a PSI is reported?

marisataylorclarke — 2023-08-31 20:43:12 UTC

All reported incidents are reviewed by a member of your local risk management or patient safety team and graded based on level of harm NHS England » Policy guidance on recording patient safety events and levels of harm . The level of harm combined with the likelihood of the incident recurring provides a measure of the potential level of risk posed to patient safety. PSIs are commonly grouped in to categories to allow surveillance of trends for further analysis, learning that may feed in to existing QI work or suggest a new area for improvement focus.

In the majority of cases, you as a trainee, will not be directly involved in this process. Local risk management or patient safety teams usually feedback trends, themes and learning through local safety newsletters, safety huddles, risk management meetings, PROMPT training and other forums. This should be covered at your local trust induction.

Other reporting requirements

marisataylorclarke — 2023-08-31 20:54:51 UTC

Trusts are required to monitor and report incidents and incident review outcomes to their local networks and Integrated Care Boards (ICBs).

Your trust may also need to report a PSI to one or more national bodies

Safe Culture

marisataylorclarke — 2023-08-31 20:55:56 UTC

A collaborative environment where everyone can flourish by :

Continuous learning and improvement of safety risks
Supportive, psychologically safe teamwork
Enabling and empowering speaking up by all

HOW DO YOU MAKE THESE PRINCIPLES PART OF YOUR DAY...?
(Link this to trainee case studies from individual units...?)

Safe system

marisataylorclarke — 2023-08-31 20:56:29 UTC

MBRRACE-UK see here for full criteria

marisataylorclarke — 2023-08-31 21:00:03 UTC

Maternal deaths
Perinatal and infant deaths
Late fetal loss
Stillbirth

PMRT see here for full criteria

marisataylorclarke — 2023-08-31 21:04:12 UTC

Late fetal loss 22⁺⁰ and 23⁺⁶ weeks and stillbirth from 24+0 showing no signs of life
All neonatal deaths where the baby is born alive from 22⁺⁰ weeks

NHS Resolution - see here for criteria

marisataylorclarke — 2023-08-31 21:04:55 UTC

CQC

marisataylorclarke — 2023-08-31 21:05:22 UTC

MNSI - criteria

marisataylorclarke — 2023-08-31 21:05:28 UTC

marisataylorclarke — 2023-08-31 21:27:48 UTC

Form R and ARCP / Reflection

marisataylorclarke — 2023-08-31 22:40:42 UTC

CLICK ABOVE FOR MORE INFORMATION...

For the purposes of Form R, you need to record any complaints and significant events that have been formally investigated by your employing organisation / Health Education England / professional body / external organisation (e.g. MNSI), or that are currently unresolved, since your last ARCP. This will be part of your sign-off discussion prior to the ARCP, and the issues may be discussed at your ARCP. The ARCP panel is interested in what you have learnt as well, and you must reflect on any significant incidents, complaints, and investigations in your e-portfolio.

Trauma Informed Care

marisataylorclarke — 2023-08-31 22:42:14 UTC

Following a PSI, what do staff need?

marisataylorclarke — 2023-08-31 22:58:30 UTC

When PSIs occur all staff have a duty and a responsibility to report what happened, actively learn, and prevent such failings happening again. This is a fundamental principle of providing

safe and harm free care for every patient.

In order to achieve a restorative just and learning culture in the aftermath of when care has not gone as expected or planned, three questions should be asked (Dekker 2017):
1) Who is hurt?
2) What do they need?
3) Whose obligation is it to meet that need?

Psychological Wellbeing

marisataylorclarke — 2023-08-31 23:00:40 UTC

Support following PSI involvement

marisataylorclarke — 2023-08-31 23:36:11 UTC

What is Duty of Candour?

hashviniyasekar — 2023-10-12 09:45:31 UTC

Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that health and care professionals must:

tell the person (or, where appropriate, their advocate, carer or family) when something has gone wrong
apologise to the person (or, where appropriate, their advocate, carer or family)
offer an appropriate remedy or support to put matters right (if possible)
explain fully to the person (or, where appropriate, their advocate, carer or family) the short and long term effects of what has happened.

Health and care professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns.

hashviniyasekar — 2023-10-12 10:25:24 UTC

Ockenden Review

marisataylorclarke — 2023-10-12 10:33:18 UTC

March 2022

East Kent Report

marisataylorclarke — 2023-10-12 10:34:11 UTC

October 2022

Morecambe Bay Investigation

marisataylorclarke — 2023-10-12 10:39:44 UTC

2015

What do I need to do when a PSI occurs?

marisataylorclarke — 2024-06-11 14:12:07 UTC

PSIs cover a broad range of incidents...

In general the first steps are :

APPG Birth Trauma Report May 2024

marisataylorclarke — 2024-07-03 05:13:57 UTC