Improving your Safety Culture? 1

Adverse Event Causation Technical Factors (30-20%) Accident Causation Human Factors Safety Culture Operator Behaviour (70-80%) = +

The way things are done around here Safety Culture “Individual and group values, attitudes, perceptions and patterns of behaviour that determine their commitment to safety management” The way things are done around here NHS Education for Scotland 2010 Ie the way things are done around here…

What would a strong safety culture look like in your place of work?

Positive Safety Culture Safety a Priority Eliminate “shame and blame” Accept staff will make errors Build systems to make care safer Foster a culture where people can speak up Team training Organizational learning from errors and near-misses

Safety In practice Culture tools Safety Climate Survey ** Trigger tool ** Significant event analysis Practices choose one

Safety Climate Survey Online Team centred Measurement Diagnosis Catalyst for change Measurement- against other practices. Prev surveys in same practice 7

Experience so far 913 GP Practices in Scotland used the survey annually for 3 years Used by 60 Auckland GP Practices since 2014 Insights Involvement Discussion Change

Insights “Many of us in the team hadn’t really made the link that us failing to communicate was a threat to patient safety ….we had a lot of really good stuff come out of it, a lot of very open discussion” 10

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The Trigger Tool and GP Detecting and Reducing Harm in Primary Care Using a Structured Case Review ( Trigger Tool ) GP / Patient Safety Advisor 12

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By screening a small sample of the records of high risk groups of patients, the team can detect and learn from ‘patient safety incidents’ that may be hidden in the records. Changes Culture – Proactively looking !

Process Choose a group of patients Sample 25 records 3 month period Look for triggers Look for harm Review Findings Identify learning and actions

Summary “Trigger review provides the GP team with important opportunities to identify patient safety incidents, individual and team learning needs and provide focus for improvement activity.”

Experience Quick Finding harm not previously identified Focus for Improvement Cultural change Training and support 20

Common Findings Adverse drug reactions - ADRs Co – prescribing Lack of follow-up Not Monitoring drugs Results handling Missed referrals Not detecting the deteriorating patient 21

“To err is human, to cover up is unforgivable and to fail to learn is inexcusable” HDC HQSC

How do you currently learn from adverse events /or excellent care How do you decide what to review? Who is involved ? What questions do you ask ? What do you do next? How do you review progress?

Significant Event Analysis is a process that helps practices answer the following questions: What happened and why? What can we learn from what happened? What needs to change? Reduces the chance of harm recurring

All need reflection discussion and teamwork

Links to Cornerstone Indicator 28 - There is an Effective Incident Management System – SEA / Trigger Tool Indicator 38 - There is a culture of safety and teamwork in practice - Climate Survey

Decide which one you are going to learn about and use Safety Climate Survey** Trigger tool ** Significant event analysis Go to the right workshop after the break !

QI Tool Session Breakout Rooms Significant Event Analysis Trigger Tool Kennedy - Lenihan Room Significant Event Analysis Phelan Room Safety Climate Survey Main Room Back to main room afterwards