Serious Incidents

Good patient safety systems supported by an open safety culture are both a ‘must have’ to get a good safety rating.  Facere Melius (FM) has experienced patient safety managers that can help organisations re-design, develop and improve safety systems.  We have successfully worked with several provider organisations placed into special measures for poor Well-led and Safety assessments, helping them to achieve rapid improvement.

 

“The Trust need to ensure that effective systems are in place to reduce the risk of safety incidents from reoccurring”1 

​

​

How we can help

​

FM has experience of working quickly and efficiently with organisations to:

• undertake independent investigations

• turnaround backlogs of outstanding serious incidents investigations;

• review Duty of Candour compliance including, undeclared non-compliance projects

• undertake thematic analysis to synthesize outstanding actions from incidents, risks, complaints, claims and internal and external reviews

• analyse the strength of actions for change from serious incidents using a hierarchy of solutions

• improve safety culture including: cultural surveys, patient safety summits and executive serious incident groups

• implement effective Learning Lessons tools.

 

“There was poor evidence of learning from serious incidents”2

 

​

Our approach

​

We work collaboratively at Board and Executive level supporting the development of Incident Management Frameworks and their alignment to the wider organisation risk and improvement processes so there is a true line of sight on incidents, risks and their management.  This has included the development of appropriate operational committees and meetings to ensure serious incidents and never events are reviewed at the right place and time. We work with all levels of the organisation to ensure understanding and involvement in patient safety, learning and improvement become a key part of managing services throughout the organisation. 

Apart from incident management assurance and reporting process experience we have Risk Management system experts who can support existing staff to maximise the impact and functionality of your current incident reporting systems to support the organisation including the roll-out of the next version of your existing systems. Throughout all of our work, we transfer knowledge to existing staff to ensure the sustainability of the robust reporting and systems frameworks we will develop.

 

CQC focus on Incident Reporting

The Care Quality Commission (CQC) will always review risk management arrangements at all levels within the organisations they inspect and recently published reports for inadequate organisations.

 

“There was not a system in place to track incidents”2

 

Risk and Safety Systems

FM has proven experience in supporting both Datix and Safeguard Systems.  Our subject matter experts have helped many organisations to: 

• resolve day-to-day system problems

• improve user experience

• undertake system audits looking at usage, set up and functionality and we will also provide recommendations for future improvements and developments 

• rebuild and re-install systems

• implementing organisational structural changes

• switch from one system to another

• ensure automatic reporting to NRLS.

 

“Ensure the grading of incidents reflect the level of harm” 2

 

Our experience

• Serious Incident Investigations training, including the duty of candour and human factors - Hospital NHS Foundation Trust

• Patient safety systems improvement; incidents, investigations and learning (patient safety summit)  - University Hospital NHS Foundation Trust

• Rebuild of the Trust patient safety and risk management system, Datix -  Hospital NHS Foundation Trust

• Rebuild of the Trust patient safety and risk management system, Safeguard - University Hospital NHS Foundation Trust

• Evaluation of patient safety system with recommendations for improvement - Hospital NHS Foundation Trust

• Serious Incident Investigations turnaround of over 100 breached investigations whilst coaching investigating officers - Hospital NHS Foundation Trust

 

 

 

References

1 Royal Cornwall Hospital NHS Trust CQC Report CQC Report 

2 Shrewsbury and Telford NHS Trust