PATIENT SAFETY NOW

Over the next few blogs, I will expand on my last blog post ‘Reality’ and talk further about the safety department I would build today if I could start over again.

Let’s start with responding to failure. If I had free rein to change things like the incident reporting system, these are the things I would do.

First, I would redesign the incident reporting system. I would tell people I want to stop adding things to the incident system. I would like to figure out what information we genuinely need to make care safer. We don’t need any more incidents adding to an already overwhelmed system.

Then I would bring together a redesign team to help:

• frontline clinicians and support staff
• patient/family representatives
• safety team
• clinical governance
• complaints
• claims
• workforce
• estates/equipment
• IT/data
• quality improvement
• someone who understands the current incident-reporting database

Second, I would map what currently gets reported. I would take the incident reports from one year and use AI to theme them. Not only the types of incident in terms of harm or impact on the patient but also ask to identify the different aspects that the reporter is trying to share:

• Was it simply to record or count something because people are worried if it isn’t written down on an incident form there wont be a record or we wont know how many times these things happen?
• Did it actually need immediate escalation?
• Did it need fixing there and then?
• Was it in relation to immediate concerns about a patient?
• Was it about problems with staff?
• Was it in fact an operational action that was required?
• Was it local learning needed because it was specific to just one place or was it useful for others to know about?
• Was it something that needed further investigation?
• Was it a way to communicate?
• Was it a way to report about individual behaviours?
• Was it about something that worked well?

I would ask the redesign team questions like:

• What are we trying to achieve?
• What do we think happened to the information?
• Have we learnt from these incidents?
• What useful outcomes did we achieve?

If a significant proportion of reports are actually requests for action, communication, maintenance, escalation, counting or documentation rather than safety intelligence I would seek to identify a better way to capture these.

Third, I would consider if these different routes would help.

Route 1: something needs fixing now – broken equipment, missing stock, staffing problem, IT problem and so on. Don’t report via an incident reporting system. Find an operational route to get it fixed. Talk to someone.

Route 2: there are immediate concerns about patient(s) or staff that need managerial intervention – concern about clinical conditions, deterioration, staffing, behaviours. Don’t report via an incident reporting system. Talk to the person or team who can act. Escalate.

Route 3. we need to count something – if we need to know the answer to ‘how many times did this happen?’ then putting it through an incident reporting system is a clumsy way of doing that. Don’t report via an incident reporting system. Use a simple mechanism such as a spreadsheet, dashboard, dataset.

Route 4: we need to learn about something- harm unexpected, events, recurrent problems where understanding the pattern matters, near misses, early warning signs, something you want to find out why it has happened. Do report via an incident reporting system.

Route 5: something is working well – adaptations that worked, successful escalation, workarounds, detecting near misses, good teamwork, prevention, improvements. Don’t report via an incident reporting system, we don’t need a parallel ‘good incident reporting system’. Find ways to capture this differently. It needs to be incredibly simple, something that can be done in 30-60 seconds. However, I am not sure we should make staff report it at all. I think learning about peoples day to day work should be part of our rebalanced approach to safety where we use different methodologies for studying how people actually create and maintain safety. (see next blog).

Fourth, I would then bring together the people who can interpret and act on the information and look at all the safety intelligence. Incident reports, complaints, claims, patient feedback, staff feedback, mortality, safeguarding, workforce information, operational pressures, equipment issues, estate issues, audits, improvement work and so on.

Our safety intelligence system should be able to answer these questions such as:

1. Where are patients being harmed?

2. Where are we seeing increasing risk?

3. Where are staff having to work around the system?

4. Where are we seeing recurring vulnerabilities?

5. Where are we seeing successful recovery and prevention?

6. What are patients and staff telling us that our other data isn’t showing?

The safety reports should then include:

• themes and patterns
• proportion of reports resulting in useful action
• number and type of incidents that identify important signals
• number of recurring problems identified
• number of issues resolved
• number of themes identified across different data sources
• examples where frontline information changed a decision
• examples of successful prevention/recovery
• proportion of reports requiring no further action
• duplicate/repetitive reporting

Fifth, we would go back to the beginning and ask, has this reduced the amount of things that are now reported via an incident reporting system and could we improve on that? Are there still a number of unnecessary reports?

And crucially, is it now become an effective safety intelligence system, and are the other routes fixing things, successfully sorting out the issues of concern, are there less recurring issues, are we learning?