1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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

9. 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?