Jump to content
  • Silent witness – My experience when filing an incident report

    • UK
    • Blogs
    • New
    • Health and care staff, Patient safety leads

    Summary

    A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.

    Content

    I am an avid fan of the show, Silent Witness; pathologists trying to find out how someone was killed just from the body. The deceased is the only witness to what actually happened. So, by looking at the surroundings is the only way of determining what might have happened.

    I also love watching 24 Hours in Police Custody. This is where they interview the person directly involved in the incident, the people around the time of the incident and the person who potentially did the crime: questioning, piecing together exactly what happened using statements, CCTV footage, verbal accounts of everyone involved. The art and science of investigation is clear. The experience and knowledge of the investigators is quite remarkable.

    Investigation in healthcare doesn’t seem to work like this.

    I am a newly qualified nurse. I have been qualified just over a year now. I reported my first Datix last month. I took over the care of a patient from a colleague. I was coming on to a night shift.

    My patient looked very unwell. I took his observations. He was scoring a 9 on the NEWS2. I put a medical emergency call out. Everyone came, they got him a bit better. They decided he was not going to do well as he was frail and had many comorbidities, they decided to keep him on the ward and if he deteriorated further, he was for palliation.

    I was pleased I had a plan for him, but I noticed that he didn’t have any observations taken for over 12 hours previously. So, I reported it as a Datix. I marked it as a serious incident. I was worried when I reported it as I didn’t know what to expect. When would someone from the investigation team come and see me? Would I have to write a statement?  When would I get interviewed? Will I get into trouble?

    I waited. The patient passed away peacefully. I forgot all about the report I had made.  

    Six weeks later I received an email. The investigation had taken place. But I wasn’t included. No one had asked me how I had found the problem, the circumstances around the problem or even asked me to be involved.

    Why?  

    I’m not trained in investigation, but surely being directly involved in an incident I would be asked what had happened and be included in their investigation?

    The email I received was to inform me of the outcome.

    ‘’Lessons learnt - Always follow the policies regarding the observation, statement taken from staff involved, practice educator involved with training.’’

    I didn’t give a statement. The member of staff who didn’t do the observations made a statement, but not me. The investigation was also ‘downgraded’.  

    What does it take to be a serious incident?  This man had no observations for over 12 hours while unwell in hospital. He deteriorated and it wasn’t recognised.  

    I think this is serious. Have others who have worked in healthcare become immune to the seriousness of incidents?

    As for the lessons learned; what are these lessons?  Telling people to do tasks isn’t good enough.

    I can’t help thinking that healthcare hasn’t got this process right. Is this the same for other hospitals?

    0 reactions so far

    8 Comments

    Recommended Comments

    Thank you dor writting, really thought provoking. Completly agree that telling people to do tasks or follow the policy (and especially 're-training' people) is not helpful or likely to improve patient safety. I'm interested to know, once you've submitted the report, what further info would you have liked to add to the investigation? I think the understanding is all the info the reporter knows is on the form as often if any queries are asked people say 'i wrote everything on the form'. Just interested as will help me think about our process (i'd like to think we dont say follow the policy in general!) But always goos to get insight

     Thank you 

    • 1 reactions so far

    Share this comment


    Link to comment
    Share on other sites

    Hi @Netty

    Patient safety 'investigators' are rarely seen in the clinical areas.  After filing a report myself (numerous times) at no point have I been asked about an incident.  Even if it was a serious one.  The only one I did get asked about was when it went to a coroners court.  

    Speaking personally, I would like someone to ask me more about the incident as there is usually so much more to it than just the report.  We usually don't have much time to fill in every detail.

    The person filling out the report usually feels strongly that something had gone wrong.  They may even have some solutions?

    I know feedback from reports is also an issue.  Often after reporting it goes off into a black hole.  We get an automated message stating it has been logged.  Then nothing.

    This feels as if nothing is being done, we don't know the process, we never find out the outcome.  It can discourage from reporting again.

    Being visible may be a start to understanding each others role and processes better?

    I would like to know how other Trusts deal with feedback from Datix (other reporting systems are available)

    • 2 reactions so far

    Share this comment


    Link to comment
    Share on other sites

    Great reply @Claire Cox

    I particularly relate to you saying the reporting person usually feels strongly about what has happened and is often motivated to complete the Datix as they want to see a positive change happen.....I have often witnessed staff staying on late to complete these....I'm sure this is a common occurrence everywhere! 

    It's very true that staff involved in the incidents often have excellent ideas as to how to avoid the same problem in the future.  I can imagine adequate staffing is a common solution!!

    If a field was added onto a Datix form template (or equivalent) asking for suggested solutions to prevent the problem from recurring in the future, it would potentially provide a wealth of ideas and evidence for consideration?  If the same solutions are frequently suggested over and over, would that suggest that the idea is highly worth considering? 

    I'm not sure if this is common practice elsewhere, but our Critical Care and High Dependency Unit specifically share feedback of incidents among staff, routinely.  One of our senior sisters who has a special interest in clinical governance reviews all incidents related to our units.  She regularly emails "incident summaries" and associated changes in practice to all unit staff.  For specific incidents, a "lessons learnt" document is attached.  These are written by various staff and allow us to make positive changes from our incidents.  Lessons learned are discussed among staff and displayed on our staff noticeboards (email receipts have even been used to help ensure the information is read).

    The Trust have recently started a "Hot Spots" monthly briefing which includes information about important clinical safety issues and staff are encouraged to share at safety huddles, handovers and briefings.  Nevertheless.... so far, I have only received one (by email)....but maybe they're in the pipeline.

    I am not so sure how the other Datix reports are shared within the rest of the hospital.  Your post prompted me to read the feedback received via email following my more recent Datix submissions...... honestly, I wish I hadn't!!  Not one feedback provided me with confidence that changes were being made....just acknowledgement of my Datix and a "now move on and bury" type of reply! It would be lovely to have the time to respond to some of the feedback received!  I believe the "Hot Spots" is a good start as will likely focus on the most common/important issues.  

    Better Datix feedback would be encouraging and educational for all involved.  Better still, a comment provided, acknowledging staff ideas (if provided), would help encourage the flow of ideas to continue........ and if the solution was not possible (often cost related) perhaps a compromise solution could be discussed. Just maybe, money saving ideas may become more everyone's business as a result. 

    I'm very interested on how and what Datix feedback is provided elsewhere?  For me, dismissive feedback is frustrating and actually discourages future reporting than providing no feedback at all!! 

    I'm not familiar with who is tasked with the Datix feedback and can appreciate time is likely a hugely limiting factor to carefully consider each response.

    Thank you for posting.  It's great to reflect on such situations and discuss with other like minded people.

    PS: It's not Datix related, but this made me think of our staff suggestions box.  Do you have one on your ward?  It might be something you and your colleagues find beneficial. 

    We all notice aspects of our work life that we would like to change (for personal reasons and for our patients/visitors)...... making suggestions for positive changes may help limit some of these gripes and make for a happier workplace in general.  We can't always expect our ideas to be materialised immediately and our managers may not have the scope that's required..... but..... often ideas are what spark off bigger things.  I often have ideas.....some unrealistic, some achievable.....I am encouraged to discuss these with management who generally share my vision....they help guide me on how I can achieve my goal and support me to make the changes required..... and it's so rewarding when you personally experience your idea soaring!! 

    Don't ever give up.....remember it will all be worth the effort eventually!

    Well done for raising your concerns. ☺️

    • 2 reactions so far

    Share this comment


    Link to comment
    Share on other sites

    Share this comment


    Link to comment
    Share on other sites

    I think collectively that many have  forgotten that reporting is about learning and taking action to prevent errors and harm. It’s not an activity my it’s own right! It’s also part of caring for and an accountability to staff, saying that we your concerns matter and we’re going to take them seriously. 
     

    Danielle, I love your suggestions. We’re going to be collating examples of great practice to share and we’ll start with these! If you’ve more detailed information or would write a blog on what you do and the impact it has, that would be wonderful. helen@patientsafetylearning.org

    • 1 reactions so far

    Share this comment


    Link to comment
    Share on other sites

    It's always a difficult one giving individual feedback and maintaining confidentiality of staff involved in incidents. It would not be appropriate to feedback that a member of staff had been taken down the HR route or been disciplined for example. 

    In relation to whether it was a "serious" incident one would hope investigators looked at whether the lapse in care/observation-taking caused or contributed to the patient's deterioration. Yes, it was below accepted standards of care but what was result of this. Despite observations not being recorded, was the patient's condition monitored and escalated appropriately anyway. All factors to be considered. This would influence the level of investigation. 

    You provide details on datix, but it is up to the investigator/team to establish the facts including obtaining information from those involved, whether there were any other circumstances to be considered, any other issues or concerns with the practice of those involved, the effect of the act or omissions on the patient etc. Your description of the incident prompts these considerations. If your description was not clear, or the investigator felt they needed more information from you, then they hopefully would have approached you to discuss further. 

    We should also identify good practice and what is done well as part of an investigation. Audit is an important part of ensuring lessons are learnt and any changes are embedded. 

    I would encourage staff to shadow their risk/governance team to get a better understanding of the issues and/or ask to be involved in root cause analysis of incidents after appropriate training. 

    • 1 reactions so far
    Edited by Deb Added info

    Share this comment


    Link to comment
    Share on other sites

    Thank you.

    'it is up to the investigator/team to establish the facts including obtaining information from those involved' Absolutely. One of the challenges that we hear is whether such people/teams have the capacity to respond as you outline. Commitment and knowledge does need to be matched with sufficient resources to investigate, learn and then take action.

    Any insights that you have of good practice, we'd love to hear from you - in a blog or sharing policies, SOPs, guidance etc. 

    Helen

    • 1 reactions so far

    Share this comment


    Link to comment
    Share on other sites

    Well done for highlighting the issue.  

    There is always a reluctance of humans to report things that are “not right”, and lots of my research has been about getting people to report incidents (accidents, near misses, security concerns). If things are not reported all that lovely data (evidence) that could be used for change is not available. No data = No appropriate change.

    The biggest barrier to reporting is feedback, and what our – oh dear – many, many studies show is that unless the feedback is immediate, appropriate, and the input appears valued, then people don’t report. Part of that feedback, in the longer term ,is evidence of change – or explanations of why things have not changed.

    Our work in getting people to report issues as soon as they see them is extensive. While success brings a warm glow to us science types – often many thousand percent increase in data in some cases, this can cause an issue possibly relevant to healthcare. I recall a heated debate where the number of incidents reported in a domain rose from 7 per month to over 300. The client was not happy – incidents, they said in a loud voice, have increased massively and we did not pay you to increase the number of accidents! Being a science type, I explained that the number of incidents was the same, you just know about them now. It took a lot of time for them to understand the difference. 

    Simply, No reports, No data, No science, No change.

    You also highlight that the investigation was not immediate – so I’ll get the ‘When to investigate' blog done soon.  I’ll also do something on getting people to report.

    Again – excellent post, if you see it, say it, and keep saying it until its sorted.  Your Human Factors community are there to support you. If someone gives you "it’s a governance issue" or even worse this is "root cause analysis", "it takes time" or "t’s a process", or you "lack the training" then simply ask – what’s my motivation to report another similar incident that’s occurs a few days later? 

    • 0 reactions so far

    Share this comment


    Link to comment
    Share on other sites

    Create an account or sign in to comment

    You need to be a member in order to leave a comment

    Create an account

    Sign up for a new account in our community. It's easy!

    Register a new account

    Sign in

    Already have an account? Sign in here.

    Sign In Now
×