Experience of patient safety investigations in England and Wales

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Introduction Experience of patient safety
investigations in England and Wales Insights
from studies funded by the DH Patient Safety
Research Programme- Original study collaborators
Prof L. Wallace Dr M. Koutantji Dr J. Benn
Prof C. Vincent Sally Adams, Prof P.
Spurgeon Coventry University Imperial College
London University of Warwick
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Research

• Scoping review and empirical survey of safety
  feedback processes for incident reporting systems
  in health care.
• Evaluation of the National Patient Safety
  Agencies RCA included training programme 8
  case studies of RCA practice in case study sites-
  examination of best practice RCAs, interviews
  with staff. (See also poster).

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Rationale for focus on feedback learning

• UK Dept of Health report An Organisation with a
  Memory (2000)
• NHS does not actively learn from failures
• Existing systems taking a long time to feed back
  information and recommendations
• There is little or no systematic follow-up of
  recommendations

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Rationale for focus on feedback learning

• National Audit Office survey of NHS trusts A
  Safer Place for Patients (2005)
• there is a need to improve sharing of solutions
  by all organisations
• lessons learnt on a local level are not widely
  disseminated either within or between trusts
• Considerable complexity in reporting and feedback
  channels currently exists (multiple agencies
  responsible)

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Patient safety policy in England Wales-

• NPSA trained staff from all trusts in England
  and Wales in RCA in 2004-5.
• RCA is mandatory for SUIs and reportable
  strategic health authorities.
• National Reporting and Learning system- no direct
  feedback to reporters.
• Major investigations- often conducted by external
  experts in addition to local teams.

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Survey of feedback learning in NHS trusts- 2006

• 351 trusts responded (out of all 607 English and
  Welsh trusts contacted) 58 response rate
• Administered between November 2005 and March 2006
• Respondent Local risk management leads
• Survey items
• Development of an open, no-blame culture
• Development and structure of local level
  reporting systems
• Analysis and use of information from incident
  reports
• Formulation and implementation of safety
  solutions
• Feedback mechanisms and methods of dissemination

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Q44 How does your organisation disseminate
lessons learnt across the Trust?
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Q45 How would you describe the guidelines/
recommendations produced based upon analysis of
incident reports?
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Q46 How would you describe the feedback that
results from incident reporting in your trust?
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Conclusions from survey

• Attention must be given to the use of information
  from incident reports to improve safety
• There is wide variation in trusts practice in
  terms of information and action feedback to front
  line work systems
• Little evaluation of impact of actions upon
  operational safety
• Feedback should be timely and targeted to
  specific practitioners
• Safety actions should be monitored and their
  effectiveness evaluated

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Exemplar RCAs

• 7 trusts submitted RCA reports- evaluated blind
  by Sally Adams
• Results 2 were of required standard, 3 partial,
  2 were merely reports of incidents or
  presentations. Lack of depth of analysis.
• Recommendations included more use of causal
  analysis tools, focus on actionable
  recommendations, more system than human
  (training!) changes. Use of external experts and
  cross trust sharing of findings, use of face to
  face methods of gaining ownership by staff of
  changes. Feedback to include users.

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Case studies- 8 trusts

• Focus of interviews
• Culture, policies, processes and structures for
  RM and investigations.
• RCA training, and roll out in trusts
• Quality of RCAs and capacity issues
• RCA- sharing and learning, externally and with
  public.

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Key findings- RCA practice

• Very positive responses re NPSA RCA course-
  problems of cascade and roll out
• If the NPSA do it, it will be correct- we are
  not interested in buying in other approaches
• Practical suggestions included use of templates
  for investigation reports, training in
  investigation interviews and facilitation
• How to ask difficult questions, setting the
  scene, to get sensible answers

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Process of RCA

• As Rick Iedema has found in Australia- RCA is
  difficult work, time consuming, challenges
  professional hierarchies and ways of doing
  things around here- findings get attenuated if
  not acceptable.
• Lack of skill in developing in depth causal
  analysis and actionable recommendations- need for
  Master classes, and feedback on conduct of RCAs.

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RCA within RM systems

• Emphasis on systems and policies- particularly
  Decision Tree (entry to RCA), little on outcome
  and feedback to staff of lessons learnt.
• Analysis of incidents- mainly numerical reports
  to boards.
• Good practice included use of targeted newsletter
  case studies of RCAs, senior staff as role models
  for conduct and use of RCA.
• our RM lead is a senior medic- she is a
  champion for RCA

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RCA and involving others

• Lack of a cadre of expertise few used external
  experts, minimal cross trust investigations or
  sharing in healthcare economy.
• Mental Health trusts embrace Patient involvement-
  not embraced in others- anxiety expressed about
  Being Open Policy.

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Key issues

• RCA needs to be part of an integrated patient
  safety system
• RCA requires skill and considerable resource
• RCA can threaten powerful vested interests
• Lessons from RCAs should be shared widely and
  impact monitored

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