1. Project Cascade – A simple technique to improve dissemination of learning points from Serious incidents and Never events
Gowrishankar S1, Meadows S2, Ameerally P.3, Cusack M.4
1Speciality Trainee, OMFS, HETV
2Governance Lead, Head and Neck, 3Consultant OMF Surgeon
4Medical Director, NGH
QUESTIONAIRE CIRCULATED
What is a Serious Incident (SI)?
2. Do you know about the most recent SI involving the Head and Neck Directorate?
3. What do you think could be done to prevent this from happening again?
4. What is the best way in which information about SI involving Head and Neck can be intimated to you?
Background
Serious Incidents (SI) include acts or omissions in care that result in unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm. Various techniques have been used to disseminate learning points from them including s, screen savers, intranet messages and safety forums but each with limited success.
Aim
To determine if we are effectively disseminating the information regarding Serious Incidents to all the staff members in the Head and Neck department
Materials & Methods
Simple questionnaire to assess the knowledge about latest SI to have occurred in Head and Neck Directorate
Questionnaire circulated to Consultants, Registrars, Core trainees, Foundation Doctors, Nurses in Oral and Maxillofacial surgery + ENT Junior doctors.
Post intervention same questionnaire circulated to determine if knowledge about serious incidents has improved.
Results
Only 50% of Consultants, 15% of the nurses, 25% of the registrars and none of Core trainees knew about the latest SI in the department pre intervention. Post intervention this rose to 100% of Consultants and Registrars and 90% of Core trainees.
Project Cascade
Governance lead chooses a serious incident to be ‘cascaded’ to staff members. This is presented at the Morbidity and Mortality meeting. Interactive discussion with suggestions from all tiers of staff which is then documented in the minutes of the meeting.
KNOWLEDGE OF SI
Pre intervention
Knowledge of SI
Post Intervention
Clinical Governance Lead for the Trust
Governance Lead in Each Directorate
Discussion and Conclusion
Project Cascade involves linking learning about serious events to a meeting already attended by Clinicians and Nurses (Morbidity & Mortaility, Nurse safety Huddle) Thus ensuring improved attendance.
Learning points are discussed INTERACTIVELY and thoughts from each tier of staff documented in minutes of the meeting. This allows scope for suggestion from all members of staff about improving safety and also a validation that the topic has been seen and discussed by individuals
Clinicians, Nursing staff, Auxiliary staff, Health Professionals
Acknowledgement
Celia Warlow, Assistant Director patient Safety & Quality Improvement
Jane Bradley, Deputy Director, Patient Safety & Quality Improvement
Project Cascade offers a simple yet effective way of disseminating learning points from serious incidents. This can be used in other units to improve patient safety.