What is Patient Safety?
According to the National Patient Safety Agency, a patient safety incident is defined as:
“Any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care.”
Duty of Candour/Being Open
Promoting a culture of openness is a prerequisite to improving patient safety and the quality of healthcare systems. It involves apologising and explaining what happened to patients who have been harmed as a result of their healthcare treatment. It ensures communication is open, honest and occurs as soon as possible following an incident. It encompasses communication between healthcare organisations, healthcare teams and patients and/or their carers.
Duty of Candour must be enacted where actual harm has occurred to a patient that has been measured as moderate, severe or death.
- Moderate harm – in essence, non-permanent serious injury or prolonged psychological harm (for example; wounds requiring further care, fractures).
- Severe harm – where permanent serious injury has occurred as a result of care provided (for example; injuries requiring surgery, life changing injuries).
- Death – The death of a patient when due to treatment received or not received (for example; a patient with a known allergy to penicillin administered said drug who then has a anaphylactic reaction and a fatal cardiac arrest).
There may be occasions where it is appropriate to embrace openness beyond the statutory duty of candour definitions, for example, where there is a significant near-miss however, this is not a statutory obligation and is covered by being open.
In broad terms, a ‘serious incident’ is an event in health care where the potential for learning is so great or the consequences to patients, families, carers, staff or the Trust is so significant, that they warrant investigation using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact an organisations ability to deliver care.
There is no definitive list of events or incidents that constitute as serious and nor should there be as this may lead to inconsistent or inappropriate management of incidents. The definitions below sets out circumstances where a serious incident should be declared recognising every incident must be considered on a case-by-case basis:
- Unexpected or avoidable death of one or more people, caused or contributed to by a weakness in care/service delivery (including lapses/acts and/or omissions) as opposed to a death which occurs as a direct result of the natural cause of the patients illness or underlying condition where this was managed in accordance with best practice.
- Unexpected or avoidable injury to one or more people that has resulted in serious harm. Serious harm can be:
- Life threatening, life changing or permanent harm is done
- Chronic pain (long term pain of more than 12 weeks)
- Psychological harm, impairment to sensory, motor or intellectual function or impairment to normal working or personal life which is not likely to be temporary (has lasted, or is likely to last for a continuous period of more than 28 days)
- Unexpected or avoidable injury to one or more people that requires further treatment by a health care professional on order to prevent, the death of the service user or serious harm.
- Actual or alleged abuse: sexual abuse, physical or psychological ill treatment, or acts of omission which constitutes neglect, exploitation, financial or material abuse, discriminative, and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where:
- The Trust did not take appropriate action/intervention to safeguard against such abuse occurring
- Where abuse occurred during the provision of NHS-funded care
This includes abuse that resulted in (or was identified through) a serious case review (SCR), safeguarding adult review (SAR), safeguarding adult enquiry or other externally led investigation, where delivery of care caused/contributed towards the incident.
Any incident that is registered with the Clinical Commissioning Group (CCG) by the Trust as a serious incident is investigated by a senior manager of the Trust.
Executive summaries of the recent serious incidents can be found here:
Details to be shown here shortly
On completion of the investigation, the outcome is presented at the Trusts ‘learning review group’ where it is reviewed; the recommendations agreed; and the action log instigated.
Learning Review Group (LRG)
The purpose of the Learning Review Group is to ensure the Trust recognises the benefits of learning from its untoward events including all events identified through complaints, concerns or the incident reporting system.
The objectives of the group are:
- To provide assurance that the Trust is investigating, reviewing and learning from high risk adverse events arising from clinical and non-clinical Serious Incidents (SI’s), Complaints, PALS, Clinical Audit, National Benchmarking, Coroners inquiries and claims to ensure continuous improvement in quality of service
- To identify concerning incident trends arising from analysis of all data collated through incident reporting, complaints, claims, Board visits, etc. both where harm/damage has occurred and near misses
- To provide recommendations to reduce both the likelihood and consequences of further similar incidents occurring
- To ensure learning is shared across all areas of the Trust and with local and national stakeholders and partners
- To review National Ambulance benchmarking and identification of learning points for West Midlands Ambulance Service
- Analysis to include Identification of risks for review or addition to the Trust Risk Register.
Its membership includes:
- Deputy Director of Nursing & Quality (Chair)
- Patient Experience Representative
- Claims Representative
- Clinical Audit Representative
- Clinical Representative
- Frontline A&E Operational Representative
- Risk Representative
- Patient Transport Services Representative
- Education and Training Representative
- Emergency Operations Centre Representative
- Staff Side Representatives
- Open invite to Non-Executives and Commissioners