Incidents

What is the track record on safety? Are lessons learnt and improvements made when things go wrong? Do staff understand their responsibilities to raise concerns, record safety incidents, concerns and near misses?”

YESTERDAY

TODAY

• There was no care bundle in place to define standard of care when discharging a patient on scene.
• Incident and SIs feared.
• Incidents were not well reported consistently.
• People felt blamed for incidents.
• People were not able to link saying sorry to the Duty of Candour.
• Lessons were not able to be embedded back into the organisation when an incident had occurred and investigation had been completed.
• Local managers did not have the skillset to be able to manage complaints and incidents so the learning was not harnessed completely.

• A non-conveyance care bundle has been developed and starting to be rolled out.
• High reporting figures, including SIs.
• Roundtable reviews set up and are being utilised to gather valuable feedback.
• Just culture and improving openness/honesty improving through engagement with staff.
• Duty of Candour training being delivered monthly.
• Lessons learnt from every SI concluded FYTD - multimedia platforms in place to share learning.
• Safety newsletter published monthly, ability to set up webinars in situ, podcasts in situ.
• Safety framework in the initial stages of being rolled out to engage with managers and all staff on safety and clinical quality.

TOMORROW

• Continued collection of data through BI tool to focus areas of improvement relating to safely discharging patients.
• The safety team is currently working on a safety climate survey. This draws on similar surveys available but is modified to suit the ambulance sector. It is anticipated that this will be launched quarterly from Q4 of the 2021/22 financial year.
• Full roll out of the Safety Framework still needs to take place including engagement event programme and setting up of dashboards to monitor local safety metrics.
• Information flow between safety and patient experience needs further work to ensure that it runs efficiently and expediates lessons back to staff.
• Ability to reach all staff effectively and reliably using the communications team and the platforms available to the Trust.
• Ability to receive assurance that all relevant staff have read and understood safety notices.
• Ability to use social media in a more effective way to ensure that safety messages are shared in a modern way and in the ways which staff would like to receive them.
• Staff are currently unlikely to know what risks are currently open on the risk register relating to safety – work should be undertaken to improve this knowledge so staff appreciate the risks posed to them, the organisation, and its patients.
• Continued work required towards completion of deliverables from the NHS Patient Safety Strategy.
• Continued work required to develop the Trust's Patient Safety Incident Response Plan in readiness for implementation of the Patient Safety Incident Response Framework.