As a new manager on an acute admission ward I was finding it difficult to review new incidents in a timely manner, giving staff feedback and learning from the incidents. The ward I was managing had 48 new incidents to review for which I struggled to find the time to review as a new ward manager. I could see from the incidents being reported, that the same incidents were re-occurring with no management plans in place to prevent or minimise the incidents from happening again.
I quickly escalated my concerns to my managers who directed me to our governance team. After lengthy discussions with our governance team, they had tried to pilot a similar project in another site with the same trust, which failed. I sat and discussed the project with our governance officer and we started a weekly re-group meeting to see how we could design a better system for reviewing incidents and essentially learning from those incidents.
We started the project from the basics and educated staff on what an incident is and provided workshops for all staff to attend. This went down really well and more and more incidents were being reported. I received more advance training on how to review an incident and the incident reporting pathways.
I found some issues with having only one reviewer of new incidents for one ward. For example if I went on annual leave or was out of office, the incidents for my ward would not be reviewed within 24 hours. I would return from leave with sometimes 25 incident to review.
I arranged for my clinical team leaders (Band 6) to be trained in reviewing incidents, which initially was refused by senior management, however after explaining the benefits, the training was eventually accepted. A Clinical Team Leader is on shift every shift (Early, Late and Nights) and therefore can review an incident the same shift and can formulate action plans to reduce the risk.
Once the workshops were finished, we then started meeting up weekly for re-group meeting to see if the project was on tack and brainstormed issues that were arising. Through these re-group meeting it was decided that a “Datix Huddle” would be the next step and we started meeting on the ward weekly to discuss the incident for that week. The Datix huddle was really welcomed by all staff, especially nurses, Doctors and Pharmacists.
At the start of the project we conducted questionnaires, which will be uploaded to this site. 72% of staff were not receiving feedback for incidents they had reported.
Incident dashboards were set up to keep track of themes or incidents we were trying to reduce.
Workshops were set up to train staff in completing incident forms and trained staff to become reviewers of incidents.
Datix huddles were started every Friday as a way of giving feedback to staff about their incidents and potentially learning from the incidents. The “Datix Huddle” concentrates on the following areas:
-Discuss weekly incidents.
-Focus on severity initially.
-Highlight active safeguarding alerts.
-Feedback incidents to staff.
Once we started meeting weekly for huddles we quickly realised themes were arising and we started to monitor these themes, for example:
-How many restraints we have had and was the patient held in prone position?
-How many AWOLS have we had?
-How many seclusion have we had?
We then designed action plans to address the above and found for example our AWOLS started to reduce. All staff participated in the huddle and a Health Care Assistant mentioned our front door took three seconds to lock. We contacted out maintenance department and now the door locks in one second. This is an example of an action, which came from our weekly huddle meetings.
Once the project was up and running you can see from the presentation uploaded, the average days an incident was overdue for review dramatically reduced from 16.89 days to 4.68 days after the workshops took place. We are currently collecting data and believe the average time for reviewing an incident is down to 1.20 days.
Staff are more informed and aware of what is happening on the ward they are working on. They are all aware of how many incidents we have had, Action plans to reduce the risk and receive regular feedback on incidents. Staff now feel incidents are worth completing, as they now no something is done about it.