Lead Researchers: Dr Janet Anderson and Dr Naonori Kodate
Programme Director: Dr Anneliese Dodds
Aims
The aim of this study is to investigate in detail how clinical teams in an acute hospital trust and in a mental health trust use incident data to increase patient safety. The study will compare and contrast the processes in these two settings. The objectives are:
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To identify the organisational learning practices that occur following major and minor adverse incidents and near misses at both Trust level, clinical care group level and the individual level
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To examine how actions following adverse incidents are decided and how the effectiveness of actions is evaluated.
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To explore the perceptions of frontline staff on the effectiveness of learning from incidents and how information about incidents impacts on their practice.
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To scope and develop interventions to improve the use of information following adverse events
Why is this important?
Incident reporting systems are now well established in the UK NHS as a means to avoid preventable adverse events and improve the quality of health care. The rationale is that they will enable hospitals to learn from adverse events and to implement improvements to care processes and systems. A lot of resources are currently invested in incident reporting systems. Despite the emphasis on incident reporting as a source of learning, little research has been done on how effectively incident data are used to address weaknesses in processes and produce safer care, in particular how frontline staff learns from incident data and their perceptions of the effectiveness of changes made following incidents. Additionally, there is little information about the role of incident data in increasing patient safety and how it might differ across different healthcare settings.
Participants
Our research is carried out in conjunction with a Research Advisory Group composed of key risk management staff at both King's College Hospital NHS Foundation Trust and South London and Maudsley NHS Foundation Trust. We will use the following research methods to collect data:
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Relevant adverse incident review meeting minutes will be analysed to investigate the development of corrective actions following major and minor incidents and near misses.
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Ethnographic observation of Trust level and Care Group (Divisional) incident review meetings will be undertaken to examine the process of discussing incidents, deciding on the actions, implementation of actions and monitoring the effectiveness of those changes.
- Semi-structured, face-to-face interviews will be undertaken with frontline staff and clinicians. Frontline staff will be interviewed about their views on the effectiveness of system improvements using information from reported incidents and the perceptions of barriers to learning, if any.
Outputs
