Learning from significant events
Case study: Orchard Court Surgery in County Durham had a system in place for reporting, recording and monitoring significant events, incidents and accidents. The practice recorded the events in categories that enabled them to look at trends, for example, medication, clinical assessment and consent, communication, and confidentiality. Significant events were reviewed on a regular basis and records showed that the practice learnt from external safety incidents to help improve the patient experience. The practice proactively sought feedback and all staff knew how to raise an issue for consideration and they felt encouraged to do so.
- Is everyone in the practice aware of the significant event process?
- Are the minutes of meetings where these are discussed available?
- Have the actions from the meetings been done and can you demonstrate how your practice has improved as a result?
- Do you have a significant event you could discuss with wider healthcare team or patient group?
- Does your practice actively seek feedback and information from other healthcare providers? Can you demonstrate this?
Sharing safety lessons with external agencies
Case study: Inclusion Healthcare Social Enterprise in Leicester shared learning from the diagnosis and treatment of a patient who had taken an overdose with the whole team and other external agencies. It then provided training to external agencies and clinical staff, and shared information with commissioners and the drug and alcohol team as a safety alert
- Does your practice have a system for acting on safety alerts?
- How are these communicated to whole practice?
- Can you provide an example to inspectors of a patient safety alert, how it was communicated and how you have confidence that all the relevant staff have seen and acted on it?
Sharing safety lessons with the MDT team
Case study: Irlam Medical Practice in Greater Manchester was able to demonstrate a strong multidisciplinary approach to learning. It shared learning from significant events with other providers and agencies in the area, so that lessons could be learned and systems changed. Significant events were discussed at multi-disciplinary practice meetings, which were attended by clinicians from other disciplines such as Macmillan nurses, safeguarding leads, community midwives or health visitors. The minutes from these meetings showed reflective practice and that information was shared to reduce risk.
- Does your practice have multi-disciplinary meetings?
- Are significant events part of these meetings?
- Can you give examples of external speakers coming to the practice and the learning that has come from this?
Training staff in safeguarding for BME patients
Case study: All staff at Deane Medical Centre in Bolton, Lancashire had received relevant training about safeguarding specific to their role, and the safeguarding lead and GP were trained to a higher level. All staff had also attended awareness training in domestic violence and female genital mutilation (FGM). Staff were also trained in communication skills regarding the correct language to use if they needed to discuss FGM with patients, and they were aware of cultural differences and attitudes. Staff were aware of the need to be alert about adults travelling abroad with children, especially during the summer holidays. There was a system for reporting suspected cases of FGM and safeguarding was an agenda item for the regular clinical and practice meetings.
- Have all your staff completed their mandatory safeguarding training?
- Are you confident that all of your staff are fully up to date with child and adult safeguarding?
- Could you run a session in your practice with the whole team to discuss child and adult safeguarding issues?
- Does everyone in your team know what to do if they have concerns with a child or adult safeguarding issue?
- How are locums made aware of local procedures? Is this information clearly displayed in the clinical rooms or on practice system so it is easy to find?
Fionnuala O'Donnell is a practice manager in Ealing, West London, and a CCG board member.
|CQC definition of practice rated outstanding for 'safe’|
People are protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things go wrong.
There is a genuinely open culture in which all safety concerns raised by staff and people who use services are highly valued as integral to learning and improvement.
All staff are open and transparent and fully committed to reporting incidents and near misses. The level and quality of incident reporting shows the levels of harm and near misses, which ensures a robust picture of safety.
Learning is based on a thorough analysis and investigation of things that go wrong. All staff are encouraged to participate in learning and to improve safety as much as possible. Opportunities to learn from external safety events are identified.
There are comprehensive systems to keep people safe, which take account of current best practice. The whole team is engaged in reviewing and improving safety and safeguarding systems. Innovation is encouraged to achieve sustained improvements in safety and continual reductions in harm.
A proactive approach to anticipating and managing risks to people who use services is embedded and is recognised as the responsibility of all staff.