1. WHAT DO JUNIOR DOCTORS KNOW ABOUT INCIDENT REPORTING? – A SURVEY BASED AUDIT Dr E Mathew FY1 Mr R McCulloch Audit & Project Lead – Mr A. Marsh Russell’s Hall Hospital, Dudley, West Midlands

2. Contents  Why is incident reporting important?  What should be reported  Relevance of junior doctors  Standard set  Questionnaire used  Results  Recommendations  E Learning Module

3. Why is Incident Reporting Important?  ‘All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity is being compromised’ GMC  Financial impact Dudley Group Policy  Early and precise gathering of facts in writing  Actions occur to identify, minimise and manage risk  Early identification of emerging patterns and trends  Improvements to policy and service delivery can be made- minimises risk of reoccurrence  Early warning occurs to forecast claims, complaints or media/external interest

4. Mid Staffs Enquiry  One of the fundamental failings at Stafford was a lack of openness resulting in lessons not being learned from mistakes – awareness of incident reporting and engaging in this process both improves patient care and protects us as healthcare professionals.

5. How Does Dudley Compare Nationally?  From the National Reporting and Learning System (NRLS) between 01/10/2011 – 31/03/2012  8.1 incidents were reported per 100 admissions  National average was 6.7/100 admissions  The two commonest incidents reported in our trust was Medication error(33%) An error of implementation of care/ongoing review(26.1%)

6. What Should be Reported?  ‘Near misses’ and ‘incidents’ should be reported  Near Miss- unexpected or unintended incident which was prevented resulting in no harm  Incident- An event or circumstance that did or could have resulted, in damage, loss or harm to person or property  Serious Incident (SI)- An incident which has resulted in death, serious injury or major public harm and is likely to lead to public concern  Subset of SIs: ‘Never Events’- SIs that should not occur if preventative measures have been put in place

7. Why Focus on Junior Doctors?  Patient safety begins with an awareness among clinicians  ‘Junior doctors are the first point of contact for most patients and need to mitigate against medical error’ (NPSA)  NPSA recommendations to improving patient safety- 5 key actions: 1. give feedback to staff 2. focus on learning 3. engage frontline staff 4. make it easy to report 5. make reporting matter

8. Trust Reporting Rates

9. Audit  All junior doctors starting at the trust in August will have signed a trust booklet on incident reporting  The content of the booklet was used as our standard to audit against with an expected score of 100%

10. Questionnaire  Formal training on clinical incidents and incident reporting  Identifying a serious incident  Recognition of a never event  The correct order to report an incident  Almost administrating Flucloxacillin to a penicillin-allergic patient is an example of..?  The best definition of risk  The best definition of root cause analysis  The 2009-2010 NHS report on never events stated that 57% of never events were due to..?  Where can you find an incident form?  Whom to contact when reporting an incident

11. Method  Questionnaire was firstly distributed electronically via e-mail, but also written questionnaires were completed during weekly teaching periods  Data collected between September and October 2012

12. Results  77% response rate from FY1 + FY2  14/40 stated that they had received formal training in incident reporting  Scores  Mean 69%  Mode 78%  Range 44% - 89%

13. Reflection & Recommendations  Results did not meet the standard set  Although the mode shows most juniors have a good awareness of incident reporting, the range implies that some do not.  The implementation of an e-learning module to accompany other induction modules  Distribute the questionnaire to other staff within the trust  Repeat the questionnaire after the e-module to assess the effectiveness of the learning event

14. What are the Aims of the E Learning Module?  To understand basic concepts and definitions within this topic  To understand the importance of incident reporting and risk management in a clinical environment  To know how to report an incident using the DATIX system  To engage in the concepts of openness and learning from mistakes

15. Contents & Format of the E Learning  Introductory slides  Interactive exercises  Process of Reporting an Incident  What happens once the incident is reported  Process of root cause analysis  Questionnaire at end of module

16. THANKS