1. Serious Untoward Incidents Trainees Experience and learning needs. Amy Thomas StR7

2. What counts as an SUI? The GMC state that “a significant incident is any unintended or unexpected event which could or did lead to harm of one or more patients…. …significant enough to be investigated by your employing organisation”.

3. Level 2Level 3  Examples of cases  Maternal deaths  Inpatient suicides (including following absconsion)*  Child protection  Data loss and information security (DH Criteria level 3-5)  Never Events  Accusation of physical misconduct or harm is made  Homicides following recent contact with mental health services*  Examples of cases  Mental Health – deaths in the community*  HCAI outbreaks  Avoidable/unexplained death  Mental health – attempted suicides as inpatients*  Ambulance services missing target for arrival resulting in death/severe harm to patient  Data loss and information security (DH Criteria level 2, see Information Resource)  Grade 3 pressure ulcer develops  Poor discharge planning causes harm to patient Root Cause Analysis Tools 2009, NPSA,NRLS

5. Survey of trainee experience. South Yorkshire.  Aim:  To understand the degree of trainee involvement in SUIs.  To improve patient safety by identifying learning needs of trainees regarding the SUI process.  Method:  An anonymous survey of Hospital trainees.  23 Specialty trainees was conducted, level CT2 - ST8.  Results were analysed and taken to the deanery Patient Safety Committee for action.

6. Survey Results  52% had been involved in an SUI.  All StR5-8.  92% had always reported the SUI.  Only 10 of 12 trainees had been asked to write a formalstatement. Indicating Level 2 or 3 severity of incident.  No trainee had attended Coroners court with regard to the SUI.

7. Survey Results  67% Trainees completed Reflective practice on the SUI.  Following the SUI Only 1 trainee received a formal investigation report.  No trainee received/required training in response to the incident.  54% received informal feedback from Clinical Supervisor.

8. How is the Trust investigation report disseminated? What happens in your hospital? Hospital A “…the report is sent to the matron and Clinical lead for the area involved”. Hospital B “…The report is sent to anyone involved, and the director of PGME if a trainee is involved”. Hospital C “..I don’t know”. Hospital D “…Everyone involved gets to approve the draft report”.

9. Survey Results  Only 23% of trainees were aware that SUI reports were required forARCP and Revalidation with the GMC.  Few had received training about the SUI process… 23% had received NHS Trust training.  4% from MPS/MDU.  9% Independent training

10. Survey Results  The majority of trainees felt training in the SUI process would beuseful. To inform them of the GMC/Deanery expectations.  To widen their perspective on improving patient safety.  Interactive lectures were preferred to Online training.

11. Discussion  Small survey of medical specialty trainees.  SUI involvement common.  Under representative of more serious SUIs.  Trainees are not receiving Trust Investigation reports.  Hospital Rotation and length of investigation?  Out of date Trust email address?  Non priority group for dissemination of information?  Ignorance of trainees?  The result is a failure to close the feedback loop to these high risk front line staff.

12. Trainee involved in SUI Trainee provides statement to allow RCA. Report and action plan produced. Learning needs addressed by Educational Supervisor? Trainee uncertain how system errors have been addressed. Trainee involved in SUI Trainee provides statement to allow RCA. Report and action plan produced. Learning needs addressed by Educational Supervisor. Trainee certain how system errors have been addressed.

13. Real life example  StR Medicine.  Asked to perform pleural tap on a patient with a pleural effusion.  He views the X-ray on the ward confirming pleural effusion on the Right hand side.  He takes patient to the ‘clinical treatment area’ where minor procedures are performed.  Performs a tap on the wrong side.  The patient arrests and is not resuscitatable.

14.  Preventable patient death.  Doctor devastated.  Doctor’s emotional and learning needs assessed by Educational Supervisor and Director of PGME.  Trust and PGME provided guidance through SUI investigation and coroners court.  When final report was released the trainee had rotated. …..the doctor remembers these hard lessons… But is he reassured the hospital he has left is any safer? Is there an “organizational memory” that will prevent this happening again? Real life

15. System and Human factors from Trust report:  There was no X ray viewing facility in procedure room!  Procedural site not marked whilst on ward…Not medical culture.  Not marked by radiologist. Not mandatory trust policy.  No WHO checklist in ‘clinical treatment area’.  Doctor confused patient’s Right with HIS Right.  Nursing auxiliaries did not challenge Doctor.

16. How do we improve the feedback loop to trainees ?  NACT Guidance 2012. “Serious Event Analysis”.  DMEs to check there is a system is in place to ensure trainees receive reports. In addition we advocate  Educational Supervisors should keep contact details for trainees who rotate and review the report with the trainee when report released.  This will close the loop, ensuring learning needs are met and informs trainee that system failures have been addressed.

17. How do we meet learning needs of Trainees?  Promotion of Deanery guidance on SUI process that is available online.  Deanery website improvement underway.  One trust is hosting “Learning events” in response to SUIs.  Still to do….  Interactive sessions with trainees about Patient Safety and the SUI process.

18. Thank you.

20. SUI process Within 1 working day. Critical incident report submitted. Risk management dept assess Grade of severity. Level 1,2 or 3 investigation triggered. Within 2 working days. Notify STEIS,CCG, and Trust Development Authority for level 2 & 3 investigations. 45-60 days Family and stakeholders kept updated. Root cause analysis and action plan generated. Report sent to CCG. If Independent investigation (report within 6months) Coroners court can trigger investigation. Within 6 months Dissemination of lessons learnt… Serious Incident Framework 2013. http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf