Walsall LPC AGM – Near Miss Reporting .

Near Miss Recording Creating the Right Culture

Problems with a punitive culture Punishment stifles reporting and learning Reduction in patient safety and quality of care Traditionally this approach, fast recognised as unacceptable

Why a no-blame culture is inadequate No-blame culture: blanket immunity Lack of accountability Not acceptable to society. Unfair Widely accepted still although lacks accountability, especially for the public.

We need the “right culture” Just culture Open culture, reporting culture, learning culture Safety and quality culture; balanced accountability and learning Fair working environment, improved patient experience, improved patient safety and quality of care

Achieving the right culture. An outline. Commitment to the right culture Recognising where it exists Getting the infrastructure right Living the right culture

Clinical Audit - part of NHS Contractual requirements Why is Near Miss reporting important? Clinical Audit - part of NHS Contractual requirements Dispensary efficiency Patient safety Clinical Governance High priority on GPhC Inspections 7

Triangle of Risk – the ratio of near miss to error rate death hospital Police/paramedic/fire service Body panel dented Car park scrapes 8

The incident iceberg and importance of near misses and “insignificant” errors (Smith, 2004)

Near Misses Through the Working Day

Human Factors Human Factors in healthcare is an approach to enhancing clinical performance through an understanding of the effects that teamwork, tasks, equipment, workspace, culture and organisation have on human behaviour and abilities. “Things that make it easier to do the right things, to the best of our ability”

Cna Yuo Raed Tihs fi yuo cna raed tihs, yuo hvae a sgtrane mnid too. Cna yuo raed tihs? Olny 55 plepoe out of 100 can. i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it dseno’t mtaetr in waht oerdr the ltteres in a wrod are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghi t pclae. The rset can be a taotl mses and you can sitll raed it whotuit a pboerlm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig huh? yaeh and I awlyas tghuhot slpeling was ipmorantt! if you can raed tihs forwrad it. Arocdnicg to rsceearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer are in the rghit pcale. The rset can be a toatl mses and you can sitll raed it wouthit pobelrm. Tihs is buseace the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. They say that only 55 people out of 100 can read that way. I would believe this number to be higher (considering that I never found someone who could not read it). What do you think?

Spot the difference?

Process / procedure design Human Factors Equipment design Environment design Process / procedure design Thinking skills Social Skills

“No Blame Culture” Responses Busy Attention Short staffed No staff Not again! Ditto marks Blanks Too rushed Which is most common? – (blanks) 15

Good Near Miss Action Plans Logs shows consistent and credible data Thought has been applied Action plan relates to findings from the audit Incorporates the whole picture SMART is present Team involvement and engagement Action is specific to the learnings generated There is a visible change of action and/or behaviour Team engagement, signed, person specific Looks at environment, people and process 16

Best Practice ‘Hints and Tips’ All team members should complete their own near miss records. Learnings and actions taken should be tangible and demonstrable. Avoid ‘concentrate more’ ‘try harder’ and ‘double check’. Review monthly and involve all team members in the review process – ownership Consider the environment as a whole – contributing factors. - ‘No near miss today’ Culture.