3.20 To ensure effective organisational learning
following patient safety incidents it is essential to cascade lessons learnt to the relevant staff groups and monitor their compliance with this new information. Trusts shared the examples of lessons learnt through clinical governance reports, internal risk management reports and trust-wide and departmental newsletters, but most used a combination of methods to disseminate learning, increasing the chance that the message gets through
(Figure 17 overleaf).
3.21 The National NHS Staff Survey 20046 showed that
only 29 per cent of respondents felt that the different parts of their trust communicated effectively with one another. We found there were other barriers to implementing lessons learnt, though many trusts had taken action to overcome these (Figure 18 overleaf). There were also wide variations in the systems for embedding organisational learning. Where monitoring of lessons identified a lack of implementation, many trusts placed the issue on the risk register, facilitated discussion of the issues between the management and staff, or gave responsibility for close monitoring to a specific committee or group.
3.22 The National NHS Staff Survey6 also found that
only 43 per cent of staff felt that their trust built strong co-operative links with other organisations. Our results also showed that sharing of best practice with external organisations was very patchy, with 63 per cent of trusts surveyed sharing learning with other local trusts, often through organised networks or the Ambulance Service Association.
Norfolk and Waveney Mental Health Partnership NHS Trust
Situation: The Saving Lives: Our Healthier Nation target has been to reduce the suicide rate by at least one fifth by 2010 and in 2002 the Trust prioritised the reduction of suicide risks. In developing an action plan, the Trust wanted to incorporate the views of the relatives of patients who had taken their own lives regarding the potential risks within the Trust’s policies and procedures. The Trust organised meetings for relatives and two representatives from the Trust to talk through some of the issues surrounding the risks for service users. A group of relatives were then supported to make recommendations to the Trust aimed at reducing suicide risks.
Action: During the two meetings, the relatives proposed recommendations involving:
n patients’ access to belts and shoelaces; n availability of information for relatives/carers; n training of unqualified staff;
n a named contact for the relatives if a patient dies; and n a single point of entry to each ward.
These recommendations were put to the Trust Board, which agreed with them in principle but also stressed that the privacy and dignity of patients should be considered at all times.
Outcome: All these points were actioned. The Trust revised its clinical standards on Additional Observation of Patients at Risk, including the need for the documentation of the rationale for the removal/ or not of potential risks of self-harm and involving the patient and carer/relative in the decisions for the care plan. Guidance was issued to staff about involving relatives in risk assessments. The Communications of Clinical Risk policy was agreed which details when the Trust may be obliged to breach confidentiality. Unregistered staff now have training regarding physical health monitoring, in addition to the same mandatory training in basic life support as registered staff. The Trust now includes a named contact in its incident file if a patient dies. All acute in-patient wards were re-designed to ensure only one point of entry and exit and the nurses stations were moved next to the entrance for better observation. The Trust have also recently introduced a swipe card system for staff and patients in one area. This system is planned for the remaining adult acute in-patient wards. The Trust has seen a reduction in the number of in-patient deaths as a result of suicide.
CASE EXAMPLE 8
Staffordshire Ambulance Service NHS Trust
Situation: Coronary Heart Disease is the single most common cause of premature death in the United Kingdom and ambulance services deal with a significant number of patients with this disease. During cardiac arrest a lack of oxygen causes brain injury within four minutes and death will occur within twelve if no therapy is given. Therefore optimal survival depends primarily on early access to emergency medical services, early cardiopulmonary resuscitation, early defibrillation and early advanced life support.
In Staffordshire approximately 3,000 people die prematurely each year as a result of cardiac arrest and Staffordshire Ambulance Service NHS Trust has adopted a number of procedures to improve its performance in treating these patients. There is clear evidence that appropriate intervention leads to increased chances of survival and the Trust uses the Advanced Medical Priority Dispatch System, which has a high sensitivity for identifying cardiac arrest cases and allows the call-taker to give pre-arrival instructions, to maximise the assistance offered to the patient before paramedics attend the scene. Although the Department’s minimum response time is eight minutes the Trust expects the first paramedic to arrive on the scene within 4 minutes and 59 seconds. The Trust has also purchased
12 lead Electrocardiograms to allow pre-hospital thrombolysis to be administered and Zoll defibrillators which store clinical performance data.
Action: The Clinical Audit Department measure and audit each individual case of cardiac arrest and acute myocardial infarction attended by the Trust, using paper and electronic patient report forms. It matches the dispatch system records with the electrocardiogram and defibrillator data, such as cardiac waveforms, blood pressures, pulse oxyimetry and an audio recording of the event.
Outcome: Ambulance crews reached 50 per cent of calls within 4 minutes and 59 seconds. Return of spontaneous circulation has increased from 22.99 per cent in 2002-03 to 25.69 per cent in 2003-04. The results of the audit and anonymous reporting of concerns about poor execution of chest compressions led to the Trust purchasing equipment to provide mechanical chest compression/heart massage for community paramedics to use during cardiopulmonary resuscitation. The Trust is now introducing these devices into the ambulance fleet. To ensure that patients receive the most effective treatments the Trust hopes to collaborate with acute trusts to facilitate the audit of the complete care pathway.
CASE EXAMPLE 9
Source: National Audit Office
The number of patients receiving pre-hospital thrombolysis in Staffordshire has increased from 137 in 2003-04 to 288 in 2004-05
Cumulative number of patients thrombolysed
March 2003 May 2003 July 2003 Sept 2003 Nov 2003 Jan 2004 March 2004 May 2004 July 2004 Sept 2004 Nov 2004 Dec 2004 Jan 2005 Feb 2005 0 50 100 150 200 250 300 350 400 450 500
3.23 Ninety-one per cent of trusts stated that they shared lessons with their strategic health authorities, but the trusts we visited felt that they were not receiving sufficient feedback. In contrast, although half of strategic health authorities used clinical governance networks as an opportunity to disseminate learning and good practice, they reported that trusts were often reluctant to share their lessons. NHS organisations were concerned that as foundation trusts are not required to report to strategic health authorities that they could miss out on information.
3.24 Since summer 2004, the National Patient Safety Agency’s 28 Patient Safety Managers have been working with most trusts to help share good practice and develop local solutions. Patient Safety Managers are well placed to improve the links between trusts and their strategic health authority and to share learning locally (Case example 10). However, just 19 per cent of trusts had shared lessons with the National Patient Safety Agency and there was a perception that it was not interested in disseminating learning from individual trusts nationally. Three-quarters of trusts did say that they were planning to increase the extent to which they shared lessons learnt with other organisations.