Skip to content

Q logo

Delivering improved learning from incidents at the care delivery / team level and creating the processes to embed the trust and culture necessary for this to be effective. A key elment is group particiption in understanding what when wrong and developeing improvements as a team.  This is a team owed process that suports sustained change.

When patient safety incidents, Serious Reportable Incidents (SIRIs) or Never Events (NEs) occur the process of understanding and learning through investigation can soon lead to a breakdown peer support and break up a team as staff are interviewd indivdually and testimonies (actually different perspectives) are plut at odds   This is especially damaging to everyone involved when the incident is a repeat of one that has happened before, and worst still, subject to an investigation, as is exposes a fundamental failure to learn from incidents.  The challenge is that Learning From Incidents (LFI) is hard and requires a difference type of investigation combined with a high degree of peer/peer and staff /managment trust.

Learning From Incidents is not root causes, it is improvement/solution focused.     Harm is not necessary for effective LFI, better to select incidents in which no one was harmed taking pressure out of the group sessions. This makes near-miss reporting an important and valuable element and contributes to a positive reprotign culture.   Many incident causes include systems, procedures and communication errors and learning from these provides detailed information on how to improve systems and prevent similar incident in future while also improving efficiency and reliability of care delivery.  LFI bonds team after an adverse event unlike root cause investigations that often fracture a team.

Repeated incidents and a failure to learn creats a culture of helpless acceptance demoralising of teams and adding significant costs.  Repted incidents are now being highlighted in the media and used as evidence that a trust, hospital or team are failing to learn.

Aims

1 The mapping of a number of incidents in bowtie / hazard defence format based on a team consensus.

2 Working in groups to identify staff suggestions for early warning indicators that they are close to an un-planned/adverse event.  While specific to the event selected for analysis it is highly probably that there will be signficant read across to a number of other situations.

3 Staff development to enable per to peer coaching on how to extract the learning and improvement opportunities events.  This contributes to a receptive and supportive team cuture

4 Engaging teams to identify the organisational processes necessary to support them in effective LFI; action tracking, follow up and simulation validation.

5 Putting in place an effective LFI system for one discipline or department that can be the exemplar for others.  Using this pilot to underpin peer to peer learning and support lead by example.

6 Evaluation of the process in an “action research” (i.e. measure and engage as we go) format.

In addition to these direct deliverables:

8 The participating teams will learn the method and supported to champion other areas to apply it.

9 Group training sessions on the method will be provided in participating organisations.

10 The method and the outcome will be written up into a “how to” style report along with the initial evaluation experience.  This report would be made freely available through Q.  The intention would also be to collect further evaluation data in due course.

 

Who Benefits?

·         The front line teams as way they work; procedures, equipment, systems, improves to prevent incidents reoccurring.

  1. ·         Patients as they no longer experience the same adverse events that have occurred in the past.
  2. ·         The Trust as repeated incidents reduce and LFI leads to a better workplace with stronger teams
  3. ·         Everyone as the culture improves as staff and patients see that they are in a learning organisation.

Why does It Matter?

A failure to learn from incidents leads to repeated incidents and repeated incidents are demoralising to staff, indicate systemic failures and undermine patient trust.  The key to breaking the cycle of repeated incidents is to embed a Learning From Incidents culture in which staff participate in developing lessons and raise issues early.

Where will this take place?

Predominantly on site and one of the Frimley Health Foundation Trust sites, most likely Wexham Park Hospital.  One longer term objective is to develop LFI for healthcare delivery in home settings as this will be an increasing focus within the developing Integrated Care System (ICS).  The initial focus will be Paediatric simulation training and feedback from events.

How you can contribute

  • Other Q colleagues are invited to participate and piggy back on this project. Project material will be available to share and trail as it is developed and opportunities welcomed for knowledge sharing and dissemination. Examples of other LFI initiatives would be helpful as would Q members who wish to pilot these approaches

Further information

FHFT_LFI_Q_Exchange_2 (DOCX, 287KB)

Comments

  1. I do like the idea of encouraging the identification of early warning indicators.  We have been running Learning from Experience meetings and it has proved popular and valuable with a number of staff returning each month (always a good sign I feel!)  and we incorporate patient stories and excellence as part of the learning opportunity too.  We have noticed that it has been good to get a variety of staff roles in the room to give a greater breadth of insight.

    I would be interested in if you have any ideas for how this can be developed in the virtual world as I have found that the virtual room goes silent when offering a opportunity of open sharing.

  2. It’s an important area, which needs more work and I’m sure getting patients / peer workers  involved in the discussions and reviews is a good idea to focus attention and also to attenuate the natural tendency to be defensive about mistakes.

     

    I cant see where your peer workers are involved in this project- perhaps you need to spell it out more?

     

  3. Have you looked into using simulation training to create a safe reconstruction of SRIs as a way of extracting the learning and improvement opportunities from the event, most notably the role of human factors? That is part of our project for #SimInPsych
    Please have a look through our proposal and offer us some support.

     

  4. I agree with Rebecca. It's a common criticism by the CQC that we fail to learn as much as we could from incidents. Any structure that facilitates spread of learning is to be welcomed.

  5. This sounds like a positive idea, building on work already undertaken in investigations & learning but with a new spin on it. I would be keen to learn more about this through Q and see how the idea, if successful, could be adapted for use in the ambulance service.

Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

* required fields

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.