Safe system framework - 5: Open and consistent learning

Open and consistent learning

How to learn and effect change that drives continous improvement? You need to consider system errors and individual responsibility. And, you need to record, investigate and evaluate incidents as well as best practice.

Responsibilities

Children, families and carers

  • Open and supported disclosure
  • Feedback to patients and families on learning from incidents and surveys

Clinicians and wider team

  • Appropriate skills and updates on taking and recording physiological observations accurately
  • Support for patients, families and staff involved or witnessing a patient safety incident, including the use of de-briefing and follow up
  • Carrying out thorough, timely investigations with actions for learning
  • Regular activities to measure, monitor and report on the processes and outcomes around spotting and treating deterioration
  • Knowledge of improvement methods

Service or organisation 

  • Support for patients, families and staff involved or witnessing a patient safety incident
  • Enabling and supporting investigations; ensuring data and information is triangulated and collective learning is endorsed across patient safety issues
  • Commitment to continuous improvement
  • Identifying positive case scenarios and learning from success
  • Awareness of medication errors including knowledge of patient safety incidents, investigations and formation of improvement plans

Regional, national, networks

  • Guidance and resources to support good quality investigations
  • National learning on patient safety incidents and issues related to deterioration in infants, children and young people, such as the National Reporting and Learning System, Child Death Overview Panels and Retrospective Case Note Reviews

Resources

Serious incident framework - a systematic process for responding to serious incidents including conducting investigations

Root cause analysis investigation toolkit - when incidents do happen it is important that lessons are learned to prevent the same incident occurring elsewhere

Children and young people’s services safety thermometer - a national tool to measure commonly occurring harms, prompts immediate actions by healthcare staff and integrates measurement for improvement into daily routines

National Patient Safety Alerts - such as the National Safety Standards for Invasive Procedures (NatSSIPs)

MedsIQ - brings together tools and improvement projects that have been developed to address medication errors affecting children and young people

NHS England patient safety - including information and guidance; Patient Safety Alerts, Patient Safety Collaboratives, Serious Incident Framework and Root Cause Analysis

NHS Improvement – patient safety information and resources now on this site, after the patient safety function was moved from NHS England to NHS Improvement in April 2016

Healthcare Safety Investigation Branch (HSIB) expert advisory group – the new HSIB website will be added as soon as available

NHS Litigation Authority –not-for-profit part of the NHS managing negligence and other claims against the NHS in England on behalf of member organisations, all of whom are provided with NHSLA score cards with their last five years claims data. This can be helpful in triangulating data alongside incident reports and complaints

References

The Health Foundation (2013) The measurement and monitoring of safety. Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring

The Health Foundation (2015) Evaluation: what to consider. This guide is intended to assist those new to evaluation by suggesting methodological and practical considerations and providing resources to support further learning.

The Health Foundation (2015) Using Communications approaches to spread improvement. This resource is intended for those actively engaged in health care improvement work and who want to explore how to best engage the right people to spread and share their findings.

Healthcare Quality Improvement Partnership (HQIP, 2016) Using root cause analysis techniques in clinical audit

CM Fernandez-Llamazares et al. Impact of clinical pharmacist interventions in reducing paediatric prescribing errors. Archives of Disease in Childhood Jun 2012;97(6):564-568

PD Hibbert, F Healey, T Lamont, WM. Marela, B Warner and WB Runciman (2015) Patient safety’s missing link: using clinical expertise to recognize, respond to and reduce risks at a population level. International Journal for Quality in Health Care, 2015, 1–8 doi: 10.1093/intqhc/mzv091

Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. (2012) Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 2012; Sep;21(9):737-45.

Jani YH, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care 2010;19:337–40

ICK Wong, S Conroy, J Collier, et al. Paediatric medication errors – the COSMIC study. Co-operative of Safety of Medicines In Children: scoping study to analyse interventions used to reduce errors in calculation of paediatric drug doses. : Department of Health report, Oct 2007, p. 276pp