I read the recent blog from a fellow nurse, ‘Silent witness’, and I too am frustrated with the current system of ‘datixing’.
Reporting is a good thing. We must report incidents; we do report incidents to try to keep our patients and staff safe. Many of us, I think, feel comfortable in reporting incidents.
However, the frustration with me is different. Yes, the feedback and the way that the reporter gets ‘missed out’ of inquiries is wrong, but the outcomes and the ‘learning’… that is where my frustration lies. I should point out at this stage of my blog; I am raging. I am so angry and frustrated at this system I could scream.
I have been a nurse now for over 20 years. I have probably filed hundreds of Datixes over the years. Some I have received feedback on, some I have not. I want to give you an insight on what I see. Not how it should be, not how you think it should be, this is how I see the system working where I am and how it makes me feel.
At present I am angry in what I see.
Where I work (in an NHS Trust) we have divisions: Medicine, Women and Children, Surgery, etc. Each one of these divisions has a head of nursing who is responsible for the safety and quality of their area, then, moving down the hierarchy, there are the matrons and then the ward managers – these are the people who would ‘investigate’ the incident that has happened, overseen by the safety and quality team (who are non-clinical).
These divisions have meetings. The frontline staff – nurses, doctors, AHPs and support staff – are not invited to these meetings. From being curious, I have determined what goes on in these meetings by shadowing my manager. In these meetings they discuss how many falls, how many acquired infections, how many serious incidents, pitching against each other to see who has performed best or better than last time.
So, by investigating the incidents that happen in your division while attempting to keep your numbers for falls, acquired infections and serious incidents low, by untrained investigators, how can these investigations be rigorous and unbiased?
In come the safety team.
I’ve never met anyone from our safety team. I don’t know where their office is. I wouldn’t know them if they walked past me in the corridor. I have no idea if they have a clinical background, but what I do know is that they do not have experience in what it is like to work in the department where I work. They don’t know the nuances, the culture, the normal deviance of behaviours or the workarounds that we use to get the work done. Perhaps if they understood...
Real life examples
I would like to share with you a few events to demonstrate how this safety process is not set up to keep patients safe; it's set up to keep the numbers of serious incidents low in that area. As I mentioned earlier, this is how it looks from my lens.
Incident 1 – Tracheostomy and laryngectomy patients
Looking after patients with tracheostomies or laryngectomies are sometimes tricky. They are high risk patients and require staff to have specialist training to care for them safely. These patients are cared for on specific wards so that patients are cohorted and cared for by staff who look after them on a regular basis.
One of these wards was a surgical ward – the ward where I work. There was an incident on this ward with a patient with a tracheostomy. The patient received significant harm and ended up on the intensive care ward as a result.
One of the outcomes from this incident was not to have laryngectomy or tracheostomy patients on this ward.
At no point was learning from the incident disseminated to staff about the causes of the incident – just remove this cohort of patients from this ward. I don’t know what we did wrong. If the situation arose again, could we do anything different? We will never know as we don’t care for these patients here now.
Incident 2 – Swallowed foreign object
An incidental finding on a chest X-ray showed that an elderly lady had swallowed her wedding ring. It was stuck in her throat. This finding was found at 23:00 at night. It was removed at 12:00 midday the following day.
A Datix report was filed as a concern was raised about the process of out of hours ENT services at my hospital. The investigation was completed. The response was that the incident was downgraded to low and that this lady was not compromised and that the ring was removed safely.
This did not address the system failure. If this was a child in our hospital, what is the provision for removing a foreign object from the throat?
Opportunity for changing and improving the current system/process was overlooked.
Incident 3 – Dehydration death and downgrade
A patient undergoing palliative bladder surgery died of dehydration on a ward less that 24 hours post-operation. The patient was not written up for any fluids, was not on a fluid balance chart and was not correctly monitored. Despite gallant efforts to rehydrate the man over the course of the night, the patient had a cardiac arrest and died.
This Datix was graded as catastrophic by the reporter, but down graded to low by investigators.
When questioned about this, the response was "his surgery was for comfort, he was going to die anyway".
Surely anyone post-operation should have fluids written up and be monitored – otherwise what is the point? Again, system failure has been overlooked and opportunities for future learning quashed.
The work we do as clinicians is complex. There needs to be an understanding of what we do and why we do it, or, sometimes, why we don’t do it. Investigating harm from an office about procedures and processes you don’t understand is ludicrous.
For my friends and family, I will not recommend this hospital I work in. It’s not a case of we don’t learn from mistakes, it’s a case of we don’t want to learn from our mistakes – it's too much effort. I don’t trust them to do the right thing.