Improving Patient Safety: Undertaking a Thematic Review of Serious Untoward Incidents
by James Valentine
Regional Quality Assurance and Compliance Lead
As part of the clinical governance process in the North Region, a thematic review of all serious incidents that had taken place between January 2021 and February 2022 was undertaken to establish areas for improvement within clinical practice. The aim was to provide oversight of the most frequent root causes of such incidents to assist with the development of strategies to better embed lessons learned and identify potential quality initiatives to improve the standards of safe care provision.
IRIS Categorisation
As part of the review process, the serious incident reports were initially broken down into the various IRIS categories with a view to establishing the types of incidents which were most frequently associated with serious incident investigations. Subsequently, it was found that in the North Region the highest proportion of incidents leading to serious incident investigation were associated with self-harm, followed closely by security (inclusive of relational and physical) as well as aggression and violence.
It was taken into consideration that these figures were impacted somewhat by the proportion of patients detained within the secure services in the region and the prevalence of complex female service users who are statistically more likely to engage with self-injurious behaviours.
Emergent Themes
There were numerous themes identified when assessing the reports, however those which were most prominent were established as: observations, security, communication and medication errors.
Regarding observations, incident reports reflected a systemic problem with the delivery of safe and supportive observations. Furthermore, there was reference to training needs for less experienced staff members undertaking this intervention, in addition to discrepancies with documentation. The second most prominent theme was security and there were several incidents of breaches of relational and physical security. Also, there were a number of recorded absconding incidents across services.
The communication of information relating to risk management and the handover of changes to specific care plans was another identified area for attention and featured in a number of the reports assessed. This was despite patients often having comprehensive risk management plans in place within their care records. Finally, there were a number of medication errors noted within the serious incidents reviewed, however, immediate reactive measures had been put in place to prevent recurrence.
Good Practice
As well as identifying areas for potential improvement, it was important to recognise areas of good practice and reflect on what had been done well during the review period. This was summarised as part of the review and shared regionally for services to reflect on the positive elements of practice highlighted.
There were lots of examples of services in the region taking positive risks with patients based upon clinical assessment of individual risks. Moreover, patients frequently had detailed risk management plans in place which were psychologically informed. There were also instances where sites had developed local training packages for their own staff teams in accordance with lessons learned and these had been successfully delivered to staff to enhance their knowledge and skills.
Overall, it very apparent from the 62 reports reviewed that the staff had dealt with a number of extraordinarily difficult situations and throughout had acted with compassion and empathy during challenging circumstances and this was commendable.
Next Steps
Following the review, the main causes of serious incidents have now been identified and shared with all services in the region. In order to take steps to improve patient safety, sites now have an individual quality action plan in place which details the specific recommendations for embedding lessons learned from their local serious incident reviews. This is monitored regularly with the view to being able to evidence reactive changes to practice and provide a baseline for further innovative proactive harm reduction strategies as part of the governance process.
The review has also provided the foundations for a Quality Improvement project in the region with the aim to reduce the frequency of serious untoward incidents associated with observations and this is due to commence during the summer 2022. It is felt that this work will assist further in maintaining a safe and supportive care environment for the patients in our care.