1. Understanding incident reporting in acute UK trusts
Understanding incident reporting in acute UK trusts. Dr Hilary Engward, PI, Anglia Ruskin University Carol Chambers, Director of Quality Assurance & Compliance, Basildon and Thurrock Trust Giles Thorpe, Deputy Director Nursing ,Colchester Hospital Trust
Context:
Patient harm is a recognized aspect of health care work.
8-12% of admissions to hospitals will involve an adverse event resulting in harm to the patient (The Health Foundation, 2015)
The measuring of organisational performance in incident reporting and learning from incidents is essential to understanding patient harm, and public accountability
In general, little is known about how healthcare organisations understand reporting, measuring, and learning from incident reporting.
We Are Asking:
What are the attitudes to incident reporting in an organisation, and how does this vary by staff group?
What systems are in place for incident reporting, and how are they used?
How is learning from serious incidents captured and codified, and how does this lead to sustained changes in practice?
How is incident reporting governed, and what assurance can this provide to stakeholders?
What are the institution-specific learning opportunities for improving incident reporting and learning?
What are the examples of good practice that can be shared with other organisations?
Further
Methodology
3 Acute Trusts
Quantitative data – survey across all staff n = 1229
Qualitative semi structured interviews, across senior and junior staff members n = 75
Regular submitted data of all incidents reported over a 1 year period (for the year 13/14).
Data on staff training in incident reporting.
Findings: 4 Themes
managing ‘grey areas’
Professional/ disciplinary tribalism: critical bystander
Reporting to meet external demands
limited learning from reporting: negative engagement
Conclusions:
Harm/potential harm needs to be better understood at the individual, directorate and executive level – grey areas
A whole staff organisational understanding to develop unified understandings, and minimises professional/discplinary silos
Datix “noise” occludes the detection of incidents from which learning ought to occur.
Staff need to see solutions/ change/ innovation as a result of the reporting process.
Staff need education on why incident reporting is important. It should not be seen as training to complete Datix.

2. Veteran Families Research Project Dr Hilary Engward, PI, Anglia Ruskin University Veterans & Families Institute Anglia Ruskin University
Context:
No UK or international research into the impact of traumatic limb loss on the family (Fossey and Hacker Hughes, 2014)
Purpose:
To identify who participants identify as “family”
Gain insight into the impact of limb loss on the Member and their family
Gain insight into variation of experiences between family units, experiences and support provided
Inform best practice in the way in which Blesma, and other stakeholders across the health and care pathways, work with families and amputees
To improve services for veterans and their families and also see if the learning is applicable to civilians P
Methodology:
Understanding the issues directly from participants – Grounded Theory approach to the research
Phase 1 unstructured interviews
Phase 2 focussed interviews
Participants
3 distinct groups:
Limb loss is attributable to your military service but NOT associated with Op Tellic or Op Herrick; OR
Limb loss occurred during service but NOT as a result of a combat injury; OR
Limb loss occurred after transition out of the military.
Further