Patient safety is integral to the high quality care we all strive to deliver in Calderdale and Huddersfield NHS Foundation Trust.
Unfortunately care does not always occur according to plan, and identifying, and learning from such events is important to improve patient care.
Following the introduction of electronic incident reporting in 2013, at CHFT we now have a wealth of information than has led to numerous service improvements. For example, as a result of an investigation of increasing number of falls, ward 5 in HRI now run multi-disciplinary team huddles to pro-actively identify at risk patients and prevent harm before it occurs. In critical care, following the investigation of a line infection it was agreed to use a chlorhexidine dressings as a standard for all patients in critical care.
Barriers to incident reporting have also been identified thanks to piloting in HRI emergency department some non-electronic incident reporting, and interviewing staff across the trust. Colleagues from clinical governance, risk management, specialist nurses and clinicians are working to improve incident and near-miss investigations in CHFT in monthly Effective Investigations Group meetings. Thanks to planned Datix simplifications and locally adapted tools from the Yorkshire and Humber Improvement Academy, better resources are being developed for incident reporting and investigations. Four training days about incident investigations, contributory factors and root cause analysis ran in May-June with good feedback. The next training days will be: 14/10/15 (HRI) and 2/11/15 (CRH).
Kath Thorley, a critical care nurse by background, is the newly appointed Trust lead for patient safety. She says: “Better incident reporting, effective investigations and focused action plans has enormous potential for improving patient care, and staff job satisfaction."
If you wish to attend an Effective Investigations training day, including learning about human error, contributory factors, cognitive interview techniques and report writing, email: Michelle Newton (clinical governance): firstname.lastname@example.org
The investigation toolkit is available on the Intranet under Divisions > Corporate > Quality & Safety > Effective Investigations and includes the fishbone diagram, tabular time lines, the Yorkshire Contributory Factors Framework and more coming soon such reporting templates. Any interested staff and patients are welcome to attend the Effective Investigations Group meetings. We are always keen to hear from more Datix users, incidents investigators and patients so that ongoing improvements can be made. Email Michelle Newton if you wish to attend or contribute or simply have a suggestion for improving the way we report, investigate and learn from incidents and near-misses.