1. Communicating with patients and/or carers about patient safety incidents - GOLD Workshop

2. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Aims To provide an overview of the Being open framework For participants to be able to put Being open in practice For participants to learn key skills that underpin effective communication with patients, their families and carers following a patient safety incident.

3. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Session 1: Background to Being open

4. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key actions from NPSA Patient Safety Alert: (2009) 1.Local policy 2.Leadership 3.Responsibilities 4.Training and support 5.Visibility 6.Supporting patients

5. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Being open Framework guidance (2009) Being open:- Policy Principles Process Patient issues Supporting staff Board leadership

6. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ NHS Constitution (2010) ‘The NHS also commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.’ (Page 11)

7. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Contractual ‘duty of candour’ to drive a more open NHS culture 4 December, 2012 New rules to toughen transparency in NHS organisations and increase patient confidence have been announced following public consultation. The government will create regulations that require NHS England to include a contractual duty of openness in all commissioning contracts from April 2013. NHS organisations will be required to tell patients if their safety has been compromised, apologise, and ensure that lessons are learned to prevent them from being repeated. Although all NHS organisations are currently expected to be open about mistakes, there is no contractual duty to hold them to account when this does not happen. Duty of Candour

8. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The benefits of Being open

9. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Patient/carer testimony 1

10. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Effects of patient safety incidents On patients and/or carers –What would be your feelings and concerns if the patient was a member of your family? –What three things do you think patients and/or carers involved in this type of incident would want most? On healthcare professionals –How would you feel if you had been one of the healthcare professionals involved? –What three things do you think healthcare teams involved in this type of incident would want most?

11. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Patient/carer testimony 2

12. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ What patients want The English public want: –34% an apology or explanation –23% an enquiry into the causes –17% support in coping with the consequences Less important were: –11% financial compensation –6% disciplinary action Source: MORI survey commissioned for the ‘Making Amends’ report, DOH, 2002

13. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ What patients want A full apology and tangible support (Idema et al., 2008) Information on the nature, cause and prevention of errors and emotional support (Gallagher et al., 2003)

14. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Being open and legal liability Mater Hospitals, Brisbane, Australia. Significant reduction in claims with savings of nearly $2 million AUD over four years Singapore: large academic hospital: no cases that proceeded to litigation for 2 years. Estimated savings of $500,000 SGD University of Michigan: full disclosure programme halved the number of pending lawsuits. Average annual saving of $US 2 million

15. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Being open and legal liability ‘It is both natural and desirable for clinicians who have provided treatment which produces an adverse result, for whatever reason, to sympathise with the patient or patient’s relatives; to express sorrow or regret at the outcome and to apologise for shortcomings in treatment. It is most important to patients that they or their relatives receive a meaningful apology. We encourage this and stress that apologies do not constitute an admission of legal liability. In addition, it is not our policy to dispute any payment, under any scheme, solely on the grounds of such an apology.’ NHSLA ‘Apologies and explanations (2009)

16. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Organisations supporting the Being open principles

17. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key elements of the Being open framework

18. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ 10 Principles of Being open

19. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Overview of Being open process

20. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Grading of patient safety incidents to determine level of response

21. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key learning points - session 1 Being open is what patients, their families and carers want to happen when an incident occurs Organisations like the NHSLA, WRP, MDU, MPS, GMC, RCN and others all support Being open Offering an apology is not an admission of legal liability There are ten Being open principles The level of Being open response is determined by an initial assessment of the severity of patient harm

22. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Session 2: Putting Being open into practice

23. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Bill and the wrong prescription

24. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Nick Oliver and the blood transfusion

25. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key learning points - session 2 Most patients want: o Acknowledgment that there has been an error o An apology (sincere, verbal and written) o An explanation o Information on what, if anything, can be done to repair the harm o Reassurance that, as far as possible, you will try to prevent recurrence Choose an appropriate lead; Consider being accompanied Establish a relationship Ask what people are feeling and need; Don’t assume Don’t be afraid to say you don’t know yet Offer and arrange a key contact

26. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Session 3: Discussing the incident, outlining the next steps and completing the process

27. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Bill and the wrong prescription

28. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Tom Slater and the laryngectomy

29. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Process completion Discuss findings of investigation and analysis Inform on continuity of care Share summary with relevant people Monitor how action plan is implemented Communicate learning with staff

30. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key learning points - session 3 Being open helps patients / carers deal with the effects of a patient safety incident Being open is a process, not a one off event Avoid making assumptions about what people are feeling and thinking. Ask; Use open ended questions Stick to the facts as they are known Document Being open discussions Speak to patients, families and carers as you would wish to be spoken to yourself, i.e. openly and honestly

31. Content from National Patient Safety Agency material http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/http:// www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Any questions? Further information can be found at: www.nrls.npsa.nhs.uk/beingopen beingopen@npsa.nhs.uk