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.

Don’t rush. You should never have to write and submit a statement immediately. It’s fine for an employer to set a deadline, but you should still have reasonable time to prepare your statement and get it checked by the RCN. Know what you’re writing about. You should be given a clear instruction or question in writing. If you haven’t been given this, ask for it. Consider if you’re at risk. If your conduct or practice is being questioned by your employer or agency, then – provided you were a member at the time of the incident – use the RCN’s statement checking service accessed via RCN Direct on 0345 772 6100. If you’re being asked to provide a statement purely as a witness, and you don’t believe there is any risk to you, simply follow the RCN guidance (link below). Be clear. Your statement should explain events from start to finish as clearly and simply as possible. Explain when things happened, who was there, and what you did, saw and heard. Try to avoid offering an opinion not based on facts. Be relevant. Do your best to answer the question or allegation you have been set. If you can’t remember something, say so. Very few people can perfectly recall every event that’s ever happened to them. Be compliant. If you’re a registered nurse, follow the National Midwifery Council's Code of Conduct, particularly the ‘Promote professionalism and trust’ section. Ensure you follow your employer’s local policies and confidentiality guidelines too. List all documents referenced in your statement. If possible, state where to find them. Format your statement. Add page and paragraph numbers, double space your lines and ensure pages have clear wide margins at each side. Check it. Review each paragraph carefully, checking that your statement only communicates exactly what was asked for or required. Look at whether you can provide evidence for the facts stated. Check the facts you provide are clearly and objectively explained. Keep a copy. You may need to refer to it in the future. The RCN’s statement writing guidance covers these tips in more detail, has a statement writing template you can use, and provides guidance on what to do if you are asked for a statement in other contexts such as if a coroner or the police ask you for a statement. Follow the link below for more information.

As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area. The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related, with procedural failures and flawed decision-making contributing in large measure. While decision support tools and information technology have gained some traction, and continue to help us progress in these areas, their universal adoption remains some way off. Until these are more widespread, we continue to rely on education and peer pressure to encourage best practice. A ‘human factors’ approach is key to understanding why errors and accidents continue to occur, despite, in many cases, adequate training, knowledge, expertise and currency. Those areas of hospitals which are under greatest stress and pressure, for example, emergency departments, continue to report a year on year increase in errors. Despite this, transfusion remains very safe indeed,with the risk of serious harm being 1 in 17,884 and death 1 in 135,705 transfused components in the UK.

Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone. There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow. One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed. Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels. Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital. The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up. Why has it been allowed to carry on? Why is there no Freedom To Speak Up Guardian at the hospital? Why has nothing been done? We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop! Actions needed We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them. Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post.

Principle 1 – Culture of safety Every organisation involved in providing NHS healthcare should actively foster a culture of safety and learning in which all staff feel safe to raise concerns. How can you describe a culture? What does it look like? I am sure that there has been many an hour at board meetings discussing this very subject. Describing the ideal safety culture is easy, we are told to adopt a ‘just culture’, however fostering a culture of safety is not that simple, following a guide doesn’t work. ‘Fostering a culture’ means to nurture and support a way of working. This principle also asks for Trusts to ‘actively foster’, to me this means that it is a dynamic action. It is not just a ‘thing’ that is said, but a ‘thing’ that you do. Working in the NHS for years, I feel I have become institutionalised, along with middle management. Bad habits are hard to break, we may start out trying to change our behaviours, but the old-world bites back. Its easy to fit in. It feels safer for us to fit in. There are multiple layers of management. Each layer has its own processes and brings with it its own culture. Hierarchy is steep in the NHS, if you do not go through the correct chain of command, you may be labelled as a troublemaker or whistleblower. This principle mentions that ALL staff should feel safe to raise concerns. As a clinician, I have the safety net of my professional body, they will support me. But what about porters, domestic and support staff or volunteers? Do they feel empowered to speak up? They may feel at the very bottom of this hierarchy. How are Trusts ensuring that they also have a voice? This principle excludes the most important group. Patients. Why are Trusts not empowering patients to speak up? Why are there no robust mechanisms for them to speak up? It is not just staff that need to feel safe in speaking up, it's patients and their families. Principle 2 – Culture of raising concerns Raising concerns should be part of the normal routine business of any well-led NHS organisation. I have raised concerns where I work, as I am sure we all have. We do it via Datix. There is a usual process. We spot the harm/concern and we log it on the computer. It gets graded by the safety team and we hear nothing back. It then happens again and the cycle repeats. This within normal behaviour. This is normal routine. Many staff are not happy with this routine of raising concerns. They have taken the effort to take the time to log the concern but feel disengaged when they hear nothing back. So why bother? They bother because it is to cover themselves and they also bother in the hope that improvements will be made. However, what if these concerns are larger. What if these concerns you have are a system wide problem? Datix is not always the correct route, it doesn’t fit. You can alert your manager, who then will alert their manager and so it goes up the chain. If at any point you feel you are not being listened to you can then go and see your Freedom to Speak Up Guardian (FTSUG). Sounds ideal. Some FTSUG work part time, some work clinically on top of this role. They are not always easily accessible. I am unclear on what value they bring to an organisation. What changes can they make? Are they listened to? Have they been put there to ‘tick the box’? Principle 3 – Culture free from bullying Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours. I have raised concerns where I work. If I follow the usual routine of raising concerns, all is good. Nothing happens. If I raise a concern outside of the normal routine, this is where the problems start. Reflecting back on a time when I raised a concern about three wards and their lack of equipment, I raised the concern with the Matron and the Patient Safety lead. More equipment needed to be purchased to prevent harm from happening to patients. This equipment was needed urgently, and I felt that the Datix system would take too long and harm would have happened before the problem was addressed. I received an email from the Head of Nursing for that area, defending why there was a lack of equipment and that I was wrong for emailing the Matron and the safety lead, that I went through the wrong channels and that she would like to see me to discuss the matter. Of course, I accepted the offer of meeting up. After all, what had I done wrong? Emailed the wrong person? Raised a concern? Had I spoken out of turn? When I received this email I felt upset and scared, then angry. This was bullying behaviour from a senior member of the Trust. I then thought, why? The Head of Nursing was known to me. She has been a real inspiration to me, so what has happened? This must be a cultural way of coping with concerns that are directly involved in the way she had managed this area. Now she was being faced with a concern raised by someone low down in the ranks, which could possibly look like an attack on the way she manages this area. Was she annoyed that she wasn’t involved in the email trail? Whatever it was, the way that the concern was raised was out of the usual. It upset the way we do things round here. I don’t want to be labelled as a whistleblower. I am doing my job and doing what the board have asked. I am raising concerns. As you see this blog is anonymous. The fear of vilification is strong and is very real. And all this with an issue where my intervention prevented a never event and for which I was thanked. With this experience, will I raise concerns again in real time to prevent harm? Or will I choose to go through the official route, wait and see if anything happens and be ready to explain (if asked) when the Trust undertakes a serious incident investigation or defends a clinical negligence claim? Principle 4 – Culture of visible leadership All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff. Initiating the FTSUG in every NHS Trust was a great idea, however, if we had visible leadership that welcomed and encouraged raising of concerns, we would not need this service. The FTSUP is a sticking plaster for a deeper routed problem. The Head of Nursing had a very human response to my concerns. She was defending actions that others had taken and defending why the problem happened. This is a natural reaction to feeling threatened, so perhaps I was in the wrong in the tone in which I raised the concern? This led me to question what training middle managers have on dealing with staff or patient concerns. When confronted with a concern do they know what to do? What do they do with this knowledge, how do they communicate with the staff or patient raising the concern? How do they raise up the line with their directors and the Board? Will they be thanked for highlighting opportunities to improve or will they be met with defensiveness and hostility? And what about ‘raising concerns’ training for staff and patients? We also need to know what is expected of us and what we can expect back, that someone has our back when we raise concerns. Principle 5 – Culture of valuing staff Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified. If adequate training in this area existed perhaps more staff and patients would speak up as they feel that they were being heard, being cared for and feel safe. In turn, middle management would feel more equipped to handle concerns with a more inquisitive approach rather than one of defence. Being involved in improvements in care is a wonderful experience. Seeing that you have made a difference to patients is a privilege. We need to react to people raising concerns in a different way, using a different lens and we all need the training and support to do so. What are Trusts doing to show that raising concerns is welcomed, makes a difference and helps us improve safety? Shouldn’t this be publicly reported to staff, to commissioners and the general public? Principle 6 – Culture of reflective practice There should be opportunities for all staff to engage in regular reflection of concerns in their work. Reflections of our concerns for work could be taken as evidence, this has been seen in the Dr Garber incident. This has made us fearful of writing our reflections down. Shwartz rounds are great but take a lot of organising and are only for the few staff. Time will always be an issue, so quick-fire reflections about what has gone wrong, and even better what has gone right, with your immediate team are a fantastic opportunity. We try and have after action reviews, however the harsh reality of clinical practice does not lend itself to a half a dozen staff downing tools to talk about just what happened. The capacity to do this is just not there. I am reflecting now on concerns that I have raised. It’s a shame I don’t feel confident in putting my name to this blog for fear of what my Trust will say. As I said, I do not want to be a whistleblower, none of us do. We want to raise concerns, have them acted on and keep our patients safe. Call for action At present the conditions are not right for us to speak up safely for these reasons: Our current reporting process doesn’t fit large system wide concerns, this is set up for incidents that have already harmed patients or staff. A Just Culture approach is spoken about but is not demonstrated or welcomed when concerns are raised. Staff are not equipped to handle concerns once they are raised to them. Patients or staff are not encouraged to speak up or have the mechanism to do so. Taking time out to reflect on our concerns and our practice is not valued. There are some great initiatives out there, but unless the fundamentals are in place to allow safe speaking up repeated harm will continue to happen.

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. Organisational structure 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). Competition time 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.

Resources LfE Quality Improvement Toolkit (based on PRAISe project) Quick start up guide LfE (July 2016) LfE top 10 tips (Jan 2017) How to get started – a few tips from our experience Framework for “reverse SIRI” (now named IRIS) – adapted from Appreciative Inquiry methodology Template (in MS word) for IRIS meetings Example LfE FAQs – for you to adapt for your organisation Mini-AI template – Mini-AI template, as used in PRAISe project 10 uses for LfE & AI LfE how to set up checklist LfE Appreciation card template – front LfE Appreciation card template – back

To use the tool, you just need to enter your height and weight into the online calculator, along with your height and weight 3-6 months ago. You will be given a rating that will tell you if you are at high, medium or low risk of malnutrition. You will then be able to download a dietary advice sheet that gives basic information and suggestions for improving nutritional intake. If you are worried about your weight or having difficulty eating, make sure you talk to your GP or a healthcare professional. The dietary advice sheet was developed in partnership with a number of professional organisations. NB this site is intended for adult self-screening only.