Patient Safety and the role of the team
Simply put, patient safety is the prevention of errors and adverse effects to patients associated with health care. Patients should be treated in a safe environment and protected avoidable harm. Patient safety is there to minimise the risk and impact of incidents occurring.
What is a Patient Safety Incident?
Patient safety incidents are any unintended or unexpected incident which could have, or did lead to harm for one or more patients receiving healthcare. Incidents can be described as either serious harm or moderate harm. We review these incidents under our Review, Learn, Improve (RLI) process. The purpose of this is not to apportion blame to any individual but to understand what went wrong and how we can put measures in place to stop it happening again.
RLI incidents are defined as those have the potential to or actually impact on patient safety or an organisations ability to continue to deliver ongoing healthcare (these would be defined under the National framework for Serious Incidents 2015).
Moderate harm incidents result in an increase in treatment, which has consequently resulted in significant, but not permanent harm.
A patient safety incident may also include adverse Incidents, which are defined as any event or circumstance that could or did lead to unintended or unexpected harm, loss or damage to any individual or the Trust.
Proper reporting ensures that we are able to learn from the error and to ensure action is taken to ensure patients stay safe.
When should incidents be reported?
The Trust is committed to delivering high-quality, safe, effective patient care and to providing a working environment where the risks to employees and others who might be affected are controlled so far as is reasonably practicable.
By having the right systems in place for reporting, reviewing and learning from adverse incidents and near misses, we are more able to respond, improving quality of care, patient and staff safety.
Staff have a duty to report and record any accident, injury, adverse incident, near miss, industrial disease and dangerous occurrence, professional malpractice or potential risk to the Trust’s business (or to individuals directly affected by its operations).
When appropriate, the Trust will then notify the relevant enforcing, regulatory and NHS monitoring authorities, including the Health and Safety Executive (HSE), National Health Service Resolution (NHSR), NHS Improvement, the Information Commissioner or the Medicines and Healthcare products Regulatory Agency (MHRA).
Examples of such incidents are (but not limited to):
- incidents that you have been involved in
- incidents that you may have witnessed
- incidents that caused no harm or minimal harm
- incidents with a more serious outcome
- prevented patient safety incidents (known as ‘near misses)
The role of the Patient Safety Team
The Patient Safety Team is responsible for identifying and managing all RLI and moderate harm incidents. They also make sure that recommendations and actions for learning are completed after each incident so that the Trust continues to improve and develop.
The team also makes sure they work with those involved to ensure the appropriate apologies are made to incidents that result in a poor experience.
The team also makes sure the Duty of Candour (see below) is followed when an incident happens. Learning and developing robust processes after incidents is very important and this information is shared throughout the Trust via a number of different routes including:
- Staff bulletin
- The patient safety forum
- The Trust's quality budding initiative
Members of the wider Governance team meet regularly with operations managers across the Trust to ensure learning is shared and discussed.
What is Duty of Candour?
It is a statutory (legal) duty to be open and honest with patients (or 'service users'), and their families, when something goes wrong that appears to have caused or could lead to significant harm in the future.
It applies to all health and social care organisations which registered with the Care Quality Commission (CQC) in England.
But what type of incidents does this cover?
The regulations define a 'notifiable safety incident' as an unintended or unexpected incident, something which could result in, or appear to have resulted in the death of a service user or severe or moderate harm ort prolonged psychological harm to the service user.
In other words, an organisation must tell you about any incident where the care or treatment may have gone wrong and appears to have caused significant harm, or has the potential to result in significant harm in the future.
So what should you expect?
You should be informed about what will happen next, including what safety measures will be taken or what enquiries or investigation will be carried out and its outcome.
You should also be told about where you can get support, such as counselling if appropriate or where to receive independent advice if required.
- tell the patient (or, where appropriate, the patient's advocate, carer or family when something has gone wrong)
- apologise to the patient (or, where appropriate, the patient's advocate, carer or family)
- offer an appropriate remedy or support to put matters right (if possible)
- explain fully to the patient (or, where appropriate, the patient's advocate, carer or family) the short and long term effects of what has happened and keep them informed
- Provide support to the patient (or, where appropriate, the patient's advocate, carer or family) through relevant means like bereavement services.
Further information on support services can be found here:
Care for the family
Care for the Family is a nationwide charity that provides parenting, relationship and bereavement support through events, resources, courses, training and volunteer networks.
Call: 029 2081 0800
Go to: www.careforthefamily.org.uk
The Child Death Helpline
The Child Death Helpline provides emotional support for anyone affected by the death of a child – whatever their age, under whatever circumstances.
The helpline is staffed by bereaved parent volunteers (not counsellors), who are trained and supported by a professional team.
Call from a landline: 0800 282 986
Call from a mobile: 0800 800 6019
The Lullaby Trust
The Lullaby Trust raises awareness of sudden infant death syndrome (SIDS), provides expert advice on safer sleep for babies. The Lullaby Trust offers confidential support to families following the sudden and unexpected death of their baby or young child, whenever and for however long it is needed. Friends and carers can also receive support.
Call: 0808 802 6868 (Bereavement advice)
Call: 0808 802 6869 (Information and advice)
Go to: https://www.lullabytrust.org.uk/
Brake is a national road safety charity. Brake supports people who have been bereaved and injured in road crashes through their helpline and range of literature.
Call: 0808 8000401
Go to: www.brake.org.uk
In addition the contact details for Patient Safety are:
Telephone: 01392 261587 or 01392 261678