How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?

1 hour ago, HelenH said:

 

How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?

Working in clinical practice is busy.  As a nurse, I dont have time to report every near miss.  I think this information is valuable and we could learn so much from it.

Even if we did capture the data - how would our safety department cope with the demand?  Perhaps a restructure on what we report and how we deal with near miss reporting needs to be addressed?

I would like to know id there is an app for reporting near misses - to make it simple and quick.  An app that is in actual use - not just in a tech company.

Hi Claire, at the Health Care Plus conference last week, when I asked the audience at a couple of sessions, some staff did say they reported near misses and were confident they would be acted upon. I didn't get a chance to follow up with them, sadly. Would be good to get more insight into 'the how.' Thoughts anyone?

Hi Claire - I think the issue of coping with the demand of increased reporting is an 'elephant in the room' issue. Otherwise we end up with yo-yo'ing between a huge surge in reports, which leads to overwhelm for those receiving them and therefore a lack of feedback to those at the front line. Which then in turn leads to a gradual decrease in reporting, and thus making it very hard for the organisation to draw any meaningful conclusions from the data - ie. Are we seeing increase/decrease in certain trends because they are happening more/less or simply because people are reporting more/less. Yet again this does come back to some extent to staffing issues, but not entirely as even in places with few/no vacancies in clinical management posts, people rarely get much/any protected time for analysing report data. I think this really comes back to the overarching PSL theme of professionalising patient safety, and part of that is seeing the analysis of report data as a vital role that needs sufficient skills, training and protected time - not just an add on to an already overloaded clinician's role.

Hi @Ben Tipney, the more I learn about effective safety management systems the more I understand how related everything is! I agree that Professionalising Patient Safety is so vital - having specialist knowledge and capacity to support the design of safer systems, analysing data, improving services and safety and evidencing that change from reporting and shared learning. Expecting over-worked clinicians to report incident and near misses when they don't have the time or confidence that anything will happen with the data will make reporting rates per se an unreliable indicator of safety performance. 

And with regard to professionalising patient safety, I don't think we have standardised role descriptions, competency frameworks and person specifications for patient safety roles. Or do we? Does anyone know whether these have been developed and if so where these might be? 

Hello Helen,

I encourage reporting  all near misses.It immediately confirms no harm to the patient, no safeguarding issue, no duty of Candour- It is just a time of praise  and congratulations  and a celebration for the team who reported it! 

Theatre staff really  need this incentive to move forward- Maybe by tapping near miss, the statistics can immediately enter into another system maybe a green light one to highlight and  keep track of data and the number of near misses reported - I am sure there's smart IT technology that can do this-