Patient safety incident response plan Effective date: September 2023 Estimated refresh date: September 2024 – February 2025
NAME
TITLE
SIGNATURE
DATE
Author
Michelle Clements
Head of Quality and Safety, Patient Safety Specialist
28.07.23
Author
Angela Harding
Quality and Safety Manager
29.09.23
Author
Tracy Rodgers
Deputy Director of Nursing and Quality
29.09.23
Reviewer
Bridgette Beal
Director of Nursing and Allied Health Professionals
29.09.23
Reviewer
Stephanie Dawe
CEO Provide Health
29.09.23
Authoriser
MSE ICB
Executive Chief Nursing Officer
02.10.23
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Contents Introduction ........................................................................................................................... 3 Our services .......................................................................................................................... 4 Defining our patient safety incident profile ............................................................................. 5 Defining our patient safety improvement profile..................................................................... 9 Our patient safety incident response plan: national requirements ....................................... 11 Our patient safety incident response plan: local focus ......................................................... 12 Local Patient Safety Priorities Planned Learning Response per incident types. .................. 17 Appendix 1 – PSIRF methodology ...................................................................................... 18
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Introduction This patient safety incident response plan sets out how Provide CIC and Provide Wellbeing intends to respond to patient safety incidents over a period of 12 to 18 months (Sept 23 – Feb 25). The plan is not a permanent rule that cannot be changed. We will remain flexible and consider the specific circumstances in which patient safety issues and incidents occurred and the needs of those affected. Incidents or themes that occur post sign off and publication of this plan will be considered for inclusion through the Provide CIC and provide Wellbeing Quality Assurance oversight via the Quality and Safety Committee, and the plan revised accordingly. The plan is underpinned by our incident management and patient safety investigations policy which is available to all staff via MyCompliance. This plan incorporates Provide Community Interest Company (CIC) and Provide Wellbeing Limited (previously Tollgate Clinic) analysis and local focus. A copy of this plan will be available to commissioners of the services within these group companies and via the Provide CIC internet site www.provide.org.uk
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Our services Provide is a Community Interest Company (social enterprise) formed on 1st April 2011. Our Vision: Transforming Lives Our Values: Care, Innovation and Compassion Our Mission: An ambitious employee-owned social enterprise, growing in size and influence. We transform lives by treating, caring and educating people.
Rated Outstanding (2019) by the CQC - Provide delivers a broad range of health and social care services in the community and are committed to making sure that they are safe, responsive, and high quality. We work from a variety of community settings, such as community hospitals, community clinics, nursing homes, and primary care settings, as well as within people's homes to provide services to children, families, and adults. We also offer some online services. We provide services across Essex, East Anglia, and Dorset.
Delivering services to a population of 4.5 million people
2 community hospitals with 36 beds (16 dedicated stroke rehabilitation beds)
employs 1000+ clinical and non-clinical staff.
providing over 40 services to support health and wellbeing of populations
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Defining our patient safety incident profile To understand the Provide CIC and Provide Wellbeing profile and priorities for the year 2023/24 we undertook a review of the previous 2 years patient safety incident data, the levels of harm and any trends. Our priority as an organisation is to ensure that our services are safe, effective, caring, responsive, and well-led and to ensure we meet these priorities we continuously collect and review a range of information about our services. To support development of this plan we reviewed data and intelligence from various sources: • • • • • • • • •
Thematic analysis of Datix incident data 2021/23 Key themes from complaints and claims and specific actions as recommended following coroner inquests. Key themes from quality and safety subgroups (safeguarding, mortality, harm free care, infection prevention, medicines) Review of referral/waiting lists to determine levels of harm and clinical risk. Actions/learning from serious incidents/never events CQC action plans and inspection outcome reports Actions arising from our internal programme of quality assurance visits. Feedback from external quality assurance visits by commissioners and regulators FFT and customer survey feedback
The team also considered learning from the iGAS outbreak of 2018/19 and the Covid 19 pandemic. The emphasis when analysing this information was to look for opportunities for improvement; areas where gaps in care and treatment and/or types of incidents remain a concern due to the impact on service users, families, carers, or staff. Additionally, we reviewed joint workstreams across the MSE collaborative, were improved patient pathways, quality of care delivery and patient experience feedback support patient safety and reduction of harms. Never Events – Provide CIC reported 1 insulin never event in September 2021 Serious Incidents – Provide CIC have reported 6 serious incidents during 2021-2023 period In determining priorities for the plan consideration was given to: •
•
Potential for harm -
People: physical, psychological, loss of trust (patients, family, carers)
-
Service delivery: impact on quality and delivery of healthcare services; impact on capacity
-
Public confidence: including political attention and media coverage.
Likelihood of occurrence -
Persistence of the risk
-
Frequency
-
Potential to escalate.
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Provide Community Interest Company (CIC)
Provide Source Incidents by Level of Harm 22/23
No harm/dama ge
Moderate harm/dama ge
Falls /1000 bed days
Minor harm/dama ge
Provide 2021
Provide 2022
NHS Benchmarking
4.2%
5.45%
6.1%
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Top 5 Categories of Provide Source Incidents Reported 22/23
Pressure Sore Issue Drug/Medication Incident Fall Patient Communication/Consent Issues Accident/Event possibly resulting in personal… 0
50
100 150 200 250
Provide Wellbeing Limited (previously Tollgate Clinic) Data and Informatics As a Provide Group company delivering NHS contracts alongside a range of self-pay services Provide Wellbeing Limited is included within the Provide PSIRF Response plan. Using the same data sources and informatics we were able to define their profile for focus in relation to delivery of services. Provide Wellbeing Ltd Incidents by type 22/23 5 4.5 4 3.5 3 2.5
Provide Community - Service User
2
Provide Community - Security and/or Information
1.5
1 0.5 0 2022 Apr
2022 Jul
2022 Nov
2022 Dec
2023 Feb
Patient safety incident response plan v4 September 2023 Page 7 of 19
Top 5 Categories Provide Wellbeing Ltd 22/23
Unwell
Referral
Medical Records
Incidents relating to personal data
Communication/Consent
0
1
2
3
4
5
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Defining our patient safety improvement profile Our Quality Assurance Patient Safety Process Our Board works in partnership with colleagues across the organisation to ensure the services we deliver achieve the standards of quality and safety required. The Board has set in place systems and processes including safe premises, safe systems of work, guidance, training, equipment, and leadership to enable colleagues to work safely and effectively. Regular assurance reports via the Quality & Safety Committee inform them how the organisation is performing with regards to quality and safety including information on incidents, risks, infection prevention, safeguarding, customer engagement, feedback, and compliments. Where needed the Board takes action to address any issues affecting quality and safety. The Board promotes a “Just culture” which supports a culture of fairness, openness and learning where staff can feel confident to speak up when things go wrong, rather than fearing blame. The Board has also set in place systems that enable staff to speak up (whistle-blow) if they are concerned about quality or safety in the organisation. They ensure that we respond to incidents and complaints promptly with openness and honesty so that we can learn from them and ensure the people affected are supported and receive an apology and explanation when things go wrong. The Board are committed to ensuring that when things do go wrong, or a person using our services experiences a harm that they are given an opportunity to share their views and experiences to support organisational learning and any resulting actions. The Board also support a culture in which good and exemplary care delivery/patient experience is recognised, celebrated, and communicated throughout the organisation. The Board ensures there is equal learning from when things go right to ensure good/positive experience of care can be spread throughout services. This is shared to a wider audience through the organisation’s Annual Quality account, annual AGM and through social media channels.
Priorities for Patient Safety Improvement Provide are committed to contributing to improvements in patient safety and support this by setting annual priorities for focus through the Annual Quality Account, internal quality objectives and wider corporate objectives and 5-year plans. Our priorities for 2023 are to focus on the systems, culture, training, and engagement to maintain an outstanding service delivery.
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Our Priorities focus on maintaining and improving: • •
•
•
Patient safety, through implementation of PSIRF and adoption of the principles of Just Culture Patient experience & customer engagement will align to PSIRF standards, including undertaking Duty of Candor (DOC). Patients of healthcare should be at the very centre of the quest to improve patient safety. Provide CIC and Provide Wellbeing Limited is committed to continuously improving the care and services we provide. We want to learn from any incident where care does not go as planned or expected by our patients, their families, or carers to prevent recurrence. We want to improve patient safety through involvement and engagement with patients, their families, carers, our Patient Safety Partner (PSP) and the wider community when a patient is involved or harmed in an incident. Clinical effectiveness and safe service delivery, through staff training (including PSS and PSIRF), recruitment and retention that reflects the organisational values, and talent management to grow a skilled and competent workforce. Our PSP will be involved in contributing to the development and design of safer healthcare at all levels in the organisation. This means maximising the things that go right and minimising the things that go wrong for patients and their families when accessing our services and receiving treatment or care. They will use their lived experience as a patient, carer, family member or a member of the local community to support and advise on activities, policies and procedures that will improve patient safety and help and inform us to deliver high quality care. They will attend meetings (face to face and online) that focus on patient safety, quality, governance, and risk.
These 3 key priorities are reflected in our patient safety incident response plan (page 12) and supported by data and informatics collated throughout Provide CIC and Provide Wellbeing. They reflect our ambitions to continually learn and improve to transform lives and keep people who use our services safe and to support our staff to deliver safe and effective services.
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Our patient safety incident response plan: national requirements Patient safety incident type
Required response
Anticipated improvement route
Incidents that meet the criteria set in the Never Events list 2018, (death/severe harm of a service user as a result of a fall (inpatient)/medication error inc insulin)
Patient Safety Incident Investigation (PSII)
Create local organisational actions and feed these into the quality improvement strategy
Deaths clinically assessed as more likely than not due to problems in care
Patient Safety Incident Investigation (PSII)
Create local organisational actions and feed these into the quality improvement strategy
Case reviews
Unexpected death of person with Learning Disability within our care
Locally led PSII if relevant Mortality Review LeDeR
Respond to recommendations as required and feed actions into the quality improvement strategy
Under 18s (child deaths)
Child Death Overview Panel
Respond to recommendations as required and feed actions into the quality improvement strategy
Incidents in NHS screening programmes
Local screening quality assurance process to inform locally led learning response
Respond to recommendations as required and feed actions into the quality improvement strategy
Safeguarding incidents in which:
Refer to local authority safeguarding lead.
Respond to recommendations as required and feed actions into the quality improvement strategy
Babies, child and young people are on a child protection plan; looked after plan or a victim of wilful neglect or domestic abuse / violence. Adults (over 18 years old) are in receipt of care and support needs by their Local Authority The incident relates to FGM, Prevent (radicalisation to terrorism); modern slavery & human trafficking or domestic abuse / violence.
Healthcare providers must contribute towards domestic independent inquiries, joint targeted area inspections, child safeguarding practice reviews, domestic homicide reviews and any safeguarding reviews (and enquiries).
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Our patient safety incident response plan: local focus Priority 1 – Deteriorating patients – community inpatient and virtual frailty wards
Clinical deterioration can occur at any point in a patient’s journey. Early recognition of the deteriorating patient, with an appropriate response and escalation can reduce patient harm and mortality. In 2016 NHS England in response to rising incidences of reported patient severe harm and death via the National Reporting and Learning System (NRLS) issued a safety alert which advocated measures to ensure organisations had the necessary systems, processes, and staff awareness in place. Areas for improvement and learning can be identified through incident reporting, complaints, coroner inquests and external alerts. Across the Provide community inpatient and virtual frailty wards measures to support early recognition and escalation have been implemented which include use of the NEWS2 tool and access to an acute based frailty consultant. It is also recognised that MDT or cross system reviews are often required to map the patients journey and ensure that learning and actions have a wider impact than our Organisation.
Quality Improvement Measures • • • •
Review to establish appropriate mechanisms for early recognition and escalation. Development of escalation/management policy across the collaborative network Ensuring that incidents that highlight caring and compassionate responses are shared across the organisation as exemplary practice. MDT and cross system working to improve the patient pathway
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Priority 2 - Wound care - Category 3 and 4 pressure ulcers (inpatient and community), Pressure ulcers continue to be the highest reported patient safety incident from the Provide CIC informatics and data profile over the past 5 years. This is reflective of both internally reported and external reported patient safety incidents. Ensuring patients receive safe and effective care that prevents and reduces pressure ulceration whilst within our care remains a high priority for Provide. Care and treatment following early identification continues to be an area of focus to prevent deterioration and associated complications such as infections. The iGAS outbreak and subsequent investigation highlighted areas for improvement in respect of pressure ulcers. Provide CIC has worked diligently since 2019 to ensure that the lessons learned are embedded in day-to-day care delivery and that vigilance and early recognition of deterioration are key to the safety netting and management of such patients. Review through coroner inquests also provides opportunity for learning and quality improvement measures also enabling opportunities for family/carer involvement and feedback. Quality Improvement Measures •
•
•
•
Wound swabs to screen for infection which may cause deterioration and delay to healing are now part of standard care delivery. Antibiotic prescribing is in line with AMR principles and monitored by the Infection Prevention Microbiologist and Medicines Team. Training and skills development is now a role competence for all registrants and nonregistrants involved in wound management. The Provide tissue viability and community nursing teams have been working in partnership and are highly involved with the roll out of the National Wound Care Strategy piloting approaches to wound management and training programmes. This early work is forming the basis of the strategy for national roll out. A programme of secondment enables all community nursing staff involved in wound care an opportunity to spend time with the tissue viability team, thereby enhancing their skills and knowledge and ensuring standards of care and treatment across the Provide organisation are equitable and evidence based. Encouraging collaborative and cross system pressure ulceration management and infection pathways to ensure continuity of care throughout the patient journey.
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Priority 3 - Medication - Insulin Safety It is estimated that more than 1 million people in the UK rely on insulin to control their diabetes (Diabetes, UK 2021). It is therefore of no surprise that medication incidents of which the drug insulin accounts for 50% of these recorded incidents is the third highest category of patient safety incidence within Provide. Insulin is classified as a high priority drug as errors in prescribing and administration can lead to severe harm or death. Whilst the majority of incidents reported within Provide are low harm/no harm, a Serious Incident related to insulin was reported and investigated in 2021. Transfer of care incidences (acute hospital discharges) also account for a considerable number of reported incidences and although may have originated within the acute hospital setting, lead to complexity of management within the community setting and in many instances an error around the insulin type administered, dosage, frequency, or device to administer. Quality Improvement Measures • Training for staff involved in insulin management – 6Rs of insulin safety. • Discharge Outcomes Group across the MSE footprint to support joint discussions around insulin safety improvements. • Patient Safety Specialist network oversight to support joint pathways of care and system improvements. • Development of joint MARs chart for use across the MSE footprint • Supporting patients and their families to models of self-management and empowerment. • Creation of learning alerts based on traffic light system (What went wrong, what did we change, what can you do to prevent reoccurrence) • Dissemination of lessons learned based on patient /family lived experience feedback
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Priority 4 - Urethral Indwelling Catheter Pathway Continence is one of the fundamentals of nursing care and maintaining continence can significantly increase a patient’s quality of life. Many people with complex health needs may need the support of continence products, such as a urethral indwelling catheter, to help them manage their everyday activities. Catheters can provide an effective way of draining the bladder, for both short and long-term purposes, however they are also associated with increased risk of infections, blockages, trauma such as penile erosions or mechanical failure. During 2021 – 2023 Provide have noted an increase in the number of reported incidents of penile erosions and infections and from performance data an increase in unplanned/SOS calls to attend to catheter issues in patient’s homes. A thematic review undertaken in 2022 highlighted a number of areas of concern which were shared within the MSE collaborative. These findings within Provide echoed similar concerns across the collaborative and a working group was convened to explore solutions and develop joint pathways.
Quality Improvement Measures • • • • •
Collaborative working group to develop joint policy and pathway. Staff training with acute bowel and bladder specialist team, including development of competence in catheterisation skills. Introduction of link nurses with enhanced skills within community teams Escalation of findings nationally to inform future work streams. Education and involvement of social care workforce to support measures for day-to-day care and management of urethral catheters
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It is noteworthy that when an incident is identified as a cross system incident. The Quality and Safety team will forward those incidents identified to the appropriate organisation’s patient safety team or equivalent. With the expectation that significant learning and improvement can be achieved for both Provide CIC and Provide Wellbeing Limited and the other organisation(s) summary reporting can be used to share insight with another provider about their patient safety profile. We will work with partner providers and the relevant Integrated Care Boards (ICBs) to establish and maintain robust procedures to facilitate the free flow of information and minimise delays to joint working on cross-system incidents. We will defer to the ICB for co-ordination where a cross-system incident is felt to be too complex to be managed as a single provider. We anticipate that the ICB will give support with identifying a suitable reviewer in such circumstances and will agree how the learning response will be led and managed, how safety actions will be developed, and how the implemented actions will be monitored for sustainable change and improvement.
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Local Patient Safety Priorities Planned Learning Response per incident types. Patient safety incident type
Required response
Anticipated improvement route
Anticipated number per quarter period
Death or severe harm clinically assessed as likely due to issues in care where immediate lifesaving treatment was required
Patient Safety Incident Investigation (PSII)
Create local organisational actions and feed these into the quality improvement strategy
Death within care (inpatient/virtual Frailty wards)
MDT Review through Mortality Review Group or
To identify areas for quality improvement and areas of good practice
≤1
<2
Swarm Huddle Moderate Harm incidents were patient required urgent referral to specialists, emergency treatment/review and/or clinically assessed as likely due to gaps in care
Patient Safety Incident Investigation (PSII) or
Moderate harm incidents clinically assessed as requiring review
MDT review through Harm Free Care Panel or
Swarm Huddle or
Create local organisational actions and feed these into the quality improvement strategy
<3
To identify areas for quality improvement and highlight areas of good practice
6 - 12
After Action Review
After Action Review Incidents were patient MDT Review or sustained moderate harm After Action review and had complex and/or deteriorating needs and cross system care delivery was involved
To examine systems and processes across the patient pathway, identifying opportunities for quality improvement
Incidents were the patient acquired a healthcare related bloodstream infection within our care
PIR
To examine systems and care delivery across the patient pathway, identifying opportunities to prevent reoccurrence
No harm/low harm incidents with a common theme that are rising in occurrence across one or more services
Thematic Review
To identify opportunities for quality improvement and measures to prevent escalation of harm
<2
≤1
≤1
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Appendix 1 – PSIRF methodology Method
Description
Patient safety incident A patient safety incident investigation (PSII) is undertaken when an investigation (PSII) incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time Multidisciplinary (MDT) review
team The multidisciplinary team (MDT) review supports health and social care teams to: • Identify learning from multiple patient safety incidents (including incidents where multiple patients were harmed or where there are similar types of incidents) • Agree, through open discussion, the key contributory factors and system gaps in patient safety incidents for which it is more difficult to collect staff recollections of events either because of the passage of time or staff availability. • To explore a safety theme, pathway, or process. • To gain insight into ‘work as done’ in a health and social care system.
After action review (AAR)
An after-action review method of evaluation usually takes the form of a facilitated discussion following an event or incident. It enables understanding of the expectations and perspectives of all those involved, and it captures learning, which can then be shared more widely. AAR generates insight from the various perspectives of the MDT and can be used to discuss both positive outcomes as well as incidents. It is based around four questions: • • • •
What was the expected outcome/expected to happen? What was the actual outcome/what actually happened? What was the difference between the expected outcome and the event? What is the learning?
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Post (PIR)
Infection
Swarm Huddle
Review The principal purpose of the Post Infection Review (PIR) is to support commissioners and providers of care to deliver zero tolerance on bloodstream infections. The purpose of the PIR is to identify how a case of bloodstream infection occurred and to identify actions that will prevent it reoccurring. This review is a cross system process and enables pathways of care and treatment to be examined to identify improvements and/or change. A swarm is designed to start as soon as possible after a patient safety incident occurs. Immediately after an incident, staff ‘swarm’ to quickly analyse what happened and how it happened and decide what needs to be done to reduce any risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. This has the benefit of staff being able to readily recall key information that may be forgotten over time, and to support staff that the aim is to identify learning and improvement in a Just Culture.
Thematic Review
A thematic review can identify patterns in data to help answer questions, show links, or identify issues. Thematic reviews can sometimes use a combination of qualitative data with quantitative data to inform findings. Thematic review can be used to inform a patient safety incident response plan, analyse a patient safety incident or theme and inform or assess the impact of a patient safety improvement plan
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