Search the hub

This year I’m seeing many more complaints on Twitter from healthcare professionals about the misuse of incident reporting. The threat “I’m going to Datix you!” is coming up time and time again and people are complaining about being “datixed” inappropriately. One Twitter user recently said: “Datix has been used as a verb so many times on my feed today that my head might explode”. Datix has become associated with fear, retribution and blame. But how has this come about and what can be done to change it? Datix as a company has seen many changes since I stood down as chief executive in 2015. The most noticeable is a change of name to RLDatix, reflecting the acquisition in 2018 of Canadian rival RL Solutions. Some things, however, have not changed. Healthcare professionals still complain about the length and complexity of the Datix forms. They still complain about the lack of action from the incident reports they submit. They still complain about getting into trouble as a result of reporting an incident themselves (particularly reports about staffing levels). And they still complain about the threat of someone else including them in an incident report as a means of coercion: “If you don’t do this, I’m going to Datix you.” All of these factors are also common to incident reporting systems from other suppliers, but because Datix has the lion’s share of the UK market, they have contributed to an overwhelmingly negative sentiment about Datix. The issues The problem with complicated and contradictory forms is that Datix gives local administrators complete freedom to design the forms themselves. This results in forms that get longer and longer over time, as new people need to collect new information. The best forms I’ve seen are very short and contain the date, the time, the reporter’s details and free text boxes for a description of what happened and what action was taken. The very best forms I’ve seen have an additional free text box: “Your safety ideas”, asking the reporter if they can think of any ways that this type of incident could be avoided or mitigated in the future. It’s a good way to encourage people to think about safety; however, it does rely on someone at the other end of the report actually listening and responding. The issue with the lack of feedback is that it relies on someone following up, investigating and then reporting back on the incident. Or if the incident isn’t going to be investigated, the reporter should be sent an explanation. If reporters don’t get any feedback and can’t see any changes made as a result of reporting, they’re going to stop reporting. This is not a problem with the incident reporting software, but an issue of the system within which it is used. The issue of the threat and fear of reporting is more deep-seated and harder to change. It’s partly linked to the other two issues – if incident reporting has no positive outcomes, it’s seen only as a burden and a tool for punishment. It’s also a symptom of a culture of fear, bullying and a lack of resources, where stressed managers want to discourage the reporting of incidents as they don’t have the time or resources to do anything about them. There are constant calls for culture change. But culture change is difficult and it’s hard to know where to start. We can, however, take incremental actions that contribute to a shift in culture. Culture change One example is the former Calgary Health Region in Canada, which had a culture where incident reporting was being used for performance management, with managers reprimanding staff who reported incidents. Recognising this was having a bad effect on staff and patients, Calgary Health Region reconfigured Datix so that the managers couldn’t see information that would identify the reporters. This didn’t change the culture overnight, but it gave staff confidence that they could report incidents in an environment free from punishment. Coupled with the setting up of a separate central department responsible for safety and investigations, this set the organisation on the long road to culture change. An excellent write up of the system that Calgary implemented can be found here. Would that system work here in the NHS? Yes it would help, but it doesn’t go far enough in a system where incident reporting has got such a bad name. We need something much more radical. What if we were to abolish incident reporting completely? Automated incident reporting systems This doesn’t mean we have to remove investigation and learning from the patient safety toolkit. It does mean that we can obtain information about incidents from places other than manually input incident report forms. The technology already exists to do this. We can monitor a hospital’s IT systems in real time to see if an incident had happened or for signs that an incident was about to happen. There would be no need to replace existing incident management systems, just the method of getting the incidents into the systems and a change to the processes around them. Such an automated incident reporting system already exists – again, in Canada – at The Ottawa Hospital. The hospital devised rules, called e-triggers, that automatically create an incident record based on certain criteria in other hospital IT systems. One such trigger might be a return to the emergency department within three days. The creation of the incident record also sends a notification to a clinician to review the record and answer some simple questions to determine if a follow up or investigation is needed. You can read some of the results from the system in this BMJ Quality & Safety paper. Although they haven’t done away with incident forms completely, this is a step in the right direction. I don’t know of anyone who has done anything similar here in the NHS, but I believe this system would go a long way towards the goal of eliminating the threat of “I’m going to Datix you”. A call to action Set up triggers to automatically send potential incidents from other IT systems into existing patient safety reporting systems. Software suppliers should take the lead on this. Simplify current incident report forms so they are as quick as possible to complete. Give clear guidance on what incident reporting should and should not be used for, with assurances that no one will get into trouble for reporting an incident or being included in an incident report. Do you have any ideas on how we can improve incident reporting and prevent the threat of “I’m going to Datix you”? Please join the discussion on the hub.

Notable achievements Working with the Office for Product Safety and Standards and the British Standards Institute to produce a guide to best practice for manufacturers and retailers of button and coin cell batteries. Instigating the Royal College of Paediatrics and Child Health and the Royal College of Emergency Medicine to produce a comprehensive guide on button battery ingestion in children covering common signs, symptoms and critical care situations. Recognising the importance of digital technology in healthcare by making multiple safety recommendations, nine to NHSX, across a number of our investigations. In our investigations with a digital impact, we discovered there were no standards for system interoperability for medication messaging; that a standardised digital care passport should be developed with a particular focus on supporting patients with autism; and, that there should be better electronic record sharing between the prison health electronic record system and the custodial services system. In the report ‘Design and safe use of portable oxygen systems’ one manufacturer decided to act quickly on HSIB's report’s safety recommendations and developed a new component to improve safe delivery of oxygen to patients. 88% of families engaging with maternity investigations. HSIB's maternity programme highlighting eight areas of learning from our initial investigations which will be developed into thematic national learning reports and published during 2020/21 (‘Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B’ report already published). Strengthening our collaborative working relationships with trusts and maternity stakeholders including, the Royal Colleges, Maternity Transformation Board, NHS Resolution and others. The relationship ensures that trusts are immediately informed when there are safety concerns, and actions implemented so similar incidents can be prevented from happening again.

Findings In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year. The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement. A varied approach to patient safety was evident on review of the corrective measures applied following the occurrence of a significant event. High efficacy corrective measures such as forcing functions, which can eliminate risk, were evident. However, in some cases, the corrective measures put in place to prevent recurrence were limited to low efficacy strategies such as re-education of staff. Undertakings should consider the risk management strategies applied to incident investigations and corrective measures to ensure they are robust and help prevent errors from reoccurring rather than punish. Overall, many of the investigation reports received by HIQA were comprehensive and showed systems based approaches to reviewing incidents. Some, however, focused on human error in isolation, without consideration of human error as a symptom of system weaknesses. Undertakings should ensure a just culture is in place where individuals feel free to report errors, assured that the response will focus on what happened, rather than who failed. This was not always evident in reports received by HIQA. Finally, it is noted that radiation incidents reported to HIQA in 2019 have involved relatively low radiation doses with limited risk to service users. The findings in this report indicate that overall the use of radiation in medicine in Ireland is generally quite safe for patients. However, radiation incidents have been reported internationally with severe detrimental effects to service users. The potential for such serious adverse events highlights the need for ongoing vigilance in relation to radiation protection and the necessity of reporting and learning frameworks. It is hoped that areas of improvement noted in this report would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland.

Key points from the survey A safety culture is critical for the protection of staff and patients. Psychological Safety for healthcare workers is an essential requirement of all safe health systems People (patient & health worker) safety is inherent in healthcare and Coproduction is the foundation of all initiatives. Measurement of what works well is essential so that there can be learning at all levels. Reporting of clinical incidents is a vital part of learning and needs to be undertaken within a just culture which is blame-free, with clear accountability. The COVID-19 pandemic revealed experiences of good practice and areas where health services need to improve, particularly in the protection of staff and looking after their mental wellbeing. Crisis management is a critical part of health services management. Managing the flow of people through the service is important to control infection.

Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their colleagues after an adverse event occurs. Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first to notice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors.

In this blog, Patient Safety Learning make the case that staff safety is intrinsically linked to patient safety. It sets out how the six foundations for safer care from the report, A Blueprint for Action, can be used to consider how making improvements to staff safety complements patient safety.[1] It looks in more detail at four key aspects of staff safety and how these areas are intertwined with improving patient safety: Physical safety – considering how the Covid-19 pandemic has highlighted the importance of this in ensuring patient and staff safety is not jeopardised. Safe staffing levels – outlining the importance of this to protect the welfare of staff and avoid creating conditions in which patient safety incidents are more likely to occur. Psychological safety – setting out the importance of having organisational cultures that enable staff to feel secure in speaking up about incidents of unsafe care, ensuring that opportunities for learning and innovation are not shut down by a blame culture. Support to staff after patient safety incidents – highlighting the key role that providing emotional support to health and social care staff who are involved in patient safety incidents can play in fostering an environment of openness and learning. It concludes by setting out the activities Patient Safety Learning will undertake over the course of September to raise awareness of, and promote action for, staff safety. References: 1. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.

This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.

Taken from the Pennsylvania Patient Safety Authority report:

The results, published in BMJ Safety & Quality, found that fewer moderate-severe IMG-related errors occurred with the user-tested guidelines compared with current guidelines, but this difference was not statistically significant. Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines compared with current guidelines. Participants who used user-tested guidelines reported greater confidence. The authors conclude that user-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.