Serious Incident Investigations. Elaine Spencer Serious incident Investigator

Transcription

1 Serious Incident Investigations Elaine Spencer Serious incident Investigator

2 Serious Incident Investigations: the brief Identifying serious incidents Levels of harm/investigation Liaising with patients and families Applying being open principles Interviewing staff System-based investigation

3 How to Identify Serious Incidents On-line reporting systems Complaints Safeguarding Whistleblowing Internal/external review structures Coroner Word of mouth

4 What are SIs Serious Incident Framework (NHS England 2015) Acts or omissions in care that result in: Unexpected or avoidable death Unexpected or avoidable injury that results in serious harm (permanent) Actual/alleged abuse Never event ( Incident/s that prevent, or threatens to prevent delivery of safe care Major loss of confidence in a service

5 Level 1 Level of investigation Concise investigation/report. Suited to less complex incidents, managed at a local level. Level 2 Comprehensive internal investigation, may involve independent/external scrutiny Level 3 Independent investigation. All members of the investigation team are independent

6 Investigation Investigation conducted for the purposes of learning to prevent recurrance Not linked to an individual but the system in which they work Understand where there are weaknesses within a system/process

7 Liaising with patients and families Acknowledgment Apology Explain

8 Duty of Candour

9 Apology Timeliness; As soon as possible after the event Consideration of timing based upon patient s health or personal circumstances Duty of Candour (within 10 working days) Verbal and written

10 Apology Truthful Meaningful Open manner Confidence Consider seniority, relationship with the patient, experience and expertise

11 Concerns Upset the patient Make the situation worse Admit liability Saying sorry is not an admission of legal liability; it is the right thing to do NHS Litigation Authority

12 Benefits of being open Reinforces a culture of openness Potentially reduces cost of litigation Improves patient experience Greater opportunity to learn Reputation of respect and trust Reputation for supporting staff when things go wrong

13 Information Sharing Information should be based solely on facts known at the time Do not speculate or attribute blame Single point of contact Contact maintained throughout the investigation Share report and offer meeting to discuss

14 Investigation Scale and scope of investigation to the incident should be proportionate Ensure effective use of resources Incidents that indicate the most significant need for learning should be prioritised

15 Investigation Wide-spread risk Multi-incident investigation Improvements being made Used as a way to manage and respond to similar incidents

16 Investigation Systems based investigation Explore the problem (what?) Contributing factors (how?) Root cause/fundamental issues (why?) Take into account environmental and human factors

17 Reason s Swiss cheese model Levels of defence LATENT CONDITIONS : poor design, procedures, management decisions etc.. Patient Safety Incident ACTIVE ERRORS

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19 People, people, people Image of people

20 Cognition Automatic Tacit knowledge Short-cuts learned from experience Rules of thumb Selected by pattern recognition Its fast, requires little mental effort It s the default process Analytical: Conscious Mental effort Deliberate Rule-based Takes time Flexible

21 Cognition Switch between these two processes What conditions affect cognition? Interruptions Emotion Tiredness & fatigue

22 Cognitive biases

23 The investigator retrospective outsider From the perspective of the outside and hindsight, the entire sequence of events is exposed the triggering conditions, its various twists and turns, the outcome, and the true nature of circumstances surrounding the route to trouble. This contrasts fundamentally with the point of view of people who were inside the situation as it unfolded around them. To them, the outcome was not known, nor the entirety of surrounding circumstances. They contributed to the direction of the sequence of events on the basis of what they saw and understood to be the case on the inside of the evolving situation. The challenge for an investigator..is to see how other people s decisions were likely nothing more than continuous behaviour reinforced by their current understanding of the situation, confirmed by the cues they were focusing on, and reaffirmed by their expectations of how things would develop Real insight comes from seeing the world through the eyes of the protagonists at the time. S Dekker Reconstructing human contributions to accidents: the new view on error and performance (2002)

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25 Interviewing staff As soon as possible (within 72 hours) Benefits of hearing the incident first hand Preparation (room, water, tissues, contact details, patient records) Explanation of process Cognitive interview technique (Geiselman & Fisher 1999)

26 Interview process Opening the interview establish rapport Explain aims of interview (your memory of events) Initiate free rapport (take yourself back..) good listener no interruptions (disrupts interviewees memory sequence) Ask to report everything Clarify and summarise Closure what happens now

27 Effective Learning - Hierarchy of effectiveness Stronger Actions Change cultural approach Architectural / physical plant or equipment changes Standardise and usability testing of equipment or care plans Simplify the process and remove unnecessary steps Degree of difficulty Moderately Strong Actions Effective use of skill mix Eliminate look and sound-a-likes Eliminate / reduce distractions Checklist / cognitive aids Weaker Actions Double checks Warnings and labels New procedure / policy Re-Training focused on an individual From: C Lee, K Hirschler. How to make the most of actions and outcomes

28 The brief. Identifying serious incidents Levels of harm/investigation Liaising with patients and families Applying being open principles Interviewing staff System-based investigation

29 Thank you Any questions?