Could it Happen Here? Eye Surgery Learning themes: Temporary worker support- inductions; Joint governance in shared working/ sub contracting, Standardised processes Escalation processes Candour and honesty, early engagement

Could it Happen Here Eye Surgery Why put patient safety first? Why learn from others? Quality is: Patient safety, patient experience and clinical outcomes. The public expect the NHS to learn, improve and share good practice. Care should include – assessment, prevention, treatment, education and communication delivered with compassion and empathy.

Could it Happen Here Eye Surgery What happened? 8th May LNFH, routine cataract list In July emerged that some patients had unexplained visual loss at follow up. Of 6 patients, 5 suffered harm 4 patients suffered significant irreversible visual loss The investigation subsequently showed that a required medication had been given by the wrong route, causing the damage

Could it Happen Here Eye Surgery What worked well? Immediate switch of medication and protocols Modified WHO check list incorporated into process Patients kept informed by senior management lead during the process and given explicit advice about clinical follow up and independent legal advice Openness & honesty of patient communication Joint working between UHS & SHFT National independent review sought

Could it Happen Here Eye Surgery What did we learn?- In your team do you have.. Surgeon attending LNFH that day was new to the Hospital- local induction Sub contracted staff - confusion around governance Follow up protocols were insufficient to detect possible problems Opportunities to standardise processes across sites Opportunities to double check medicines Information shared with patients – they still came back to LNFH for follow up

Could it Happen Here Eye Surgery What are we doing differently? Changes to policy, review of policy dissemination in division Formal induction process for new staff, including temporary Jointly agreed governance process between partner providers Open & Honest approach to learning and sharing Clarity around process for escalation MDT engagement in Critical incident review panels from May 2014 Active engagement with patients in their care- leaflet

Could it Happen Here Eye Surgery Discussion – 10mins Could it happen here? What was the effect to patient safety, patient experience and clinical outcome? Is it acceptable to your professional and organisation values?

Could it Happen Here Eye Surgery How do we prevent the incident happening again? How do we introduce good practice? How do we embed and audit good practice? Discussion 10mins

Could it Happen Here Eye Surgery What have you learnt from this incident? What will you do differently to improve patient safety, patient experience and clinical outcome? What 3 things will you do today to ensure it doesn’t happen here?