NHS Resolution’s Safety and learning service piloted a project in conjunction with Datix and Ulysess to examine the strengths of the links between incidents, complaints and claims. There are four sites, one in each of the regions:
- North – North Tees and Hartlepool Hospitals NHS Foundation Trust
- London – Royal Free London NHS Foundation Trust
- Midlands & East – University Hospitals Coventry & Warwickshire NHS Trust
- South – Taunton & Somerset NHS Foundation Trust
The pilot is now complete. The purpose was to explore common contributory factors identified in orthopaedic and obstetric claims that can be identified earlier so patient harm can be reduced.
The focus was for local incident providers to support members’ bespoke safety reporting and around NHS Resolution providing more direct support to members.
Overall, the pilot was a success as all four trusts benefitted from shared learning across teams within their organisations and identified improved approaches that will confer greater candour and openness. Some trusts additionally identified new creative ways to improve patient safety learning (such as: learning and simulation training for serious incident investigation, an online incident library, a cross-directorate Datix report team and a multidisciplinary rapid response team).
However, each of the four trusts approached the data analysis differently, yielding contributory triggers for harm that were unique to their trust. This needs to be considered in any future plans and whole system rollout to the membership. Similarly, consideration needs to be give to the apparent absence of an effective automated electronic alert system that works across different clinical specialities within the same organisation, across different sites and also with outside organisations is needed.
If you would like further information, contact our safety and learning service