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Professor Damian Roland is a paediatric emergency medicine clinician scientist and head of service for the Children's Emergency Department at Leicester Royal Infirmary.
As Damian discusses on the podcast, in order to learn from harm and prevent it occurring again we need to collect data and investigate what is occurring across the healthcare system rather than looking to individuals. Removing the individual, more punitive approach to harm investigations could improve the quality of how we record and report harm.
There is already a wealth of learning available from a range of sources including national reports, coroner’s findings described in regulation 28 reports to prevent future death and large-scale reviews like those of the Health Services Safety Investigations Body. We can investigate whether the causes of harm identified in these reports are occurring where we work and make proactive steps to avert it.
Damian also shares the progress of the SPOT programme (System-wide Paediatric Observation Tracking) which looks to reduce harm and improve how we learn from harm by creating a standardised common language to identify and discuss children whose health is deteriorating.
Thank you for listening.
Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement | Produced by 18Sixty
Please be advised that this podcast series contains stories relating to child death and harm. All views, thoughts and opinions expressed belong to the guests and not necessarily to their employer, linked organisations or RCPCH.
- About the speaker, Professor Damian Roland
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Damian is a paediatric emergency medicine clinician scientist and is head of service for the Children's Emergency Department at Leicester Royal Infirmary.
Among his many achievements, Damian has been focused on addressing the challenges of identifying deterioration in health in children. He created the Paediatric Observation Priority Score for Children's Emergency Care and currently he is instrumental in the NHS England SPOT programme.
- About the Patient Safety series
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As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings.
We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.
The RCPCH Patient Safety Portal has lots of resources. It includes a wealth of information summarising reports and investigations that identify what puts children at risk of harm. It is imperative to turn this knowledge into action through improvement activities.
- Topics/organisations/papers referenced in this episode
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- John Madar (PDF)
- Datix
- Health Services Safety Investigations Body
- Royal College of Emergency Medicine
- René Amalberti
- Adrian Plunkett
- Learning from Excellence
- David Sinton (on X)
- POPS (Paediatric Observation Priority Score for Children’s Emergency Care) - (PDF)
- Swiss Cheese Model (on National Library for Medicine)
- NHSE SPOT: System-wide Paediatric Observation Tracking programme - guidance
- Emma Lim
- Critically Careful forums (University Hospitals of Leicester NHS Trust)
- Peter Lachman
- Ronny Cheung
- Eric Hollnagel: From Safety-1 to Safety II (PDF)
- Charles Vincent
- Mary Dixon Woods: How to improve healthcare improvement - BMJ
- The Health Foundation
- Creating Communities of Practice
- Rhizomology - Rhizomatic Knowledge Communities, Edtechtalk, Webcast Academy