1. Improving your Safety Culture?1

2. Adverse Event Causation
Technical
Factors
(30-20%)
Accident
Causation
Human
Factors
Safety
Culture
Operator
Behaviour
(70-80%) = +

3. The way things are done around here
Safety Culture
“Individual and group values, attitudes, perceptions and patterns of behaviour that determine their commitment to safety management”
The way things are done around here
NHS Education for Scotland 2010
Ie the way things are done around here…

4. What would a strong safety culture look like in your place of work?

5. Positive Safety Culture
Safety a Priority
Eliminate “shame and blame”
Accept staff will make errors
Build systems to make care safer
Foster a culture where people can speak up
Team training
Organizational learning from errors and near-misses

6. Safety In practice Culture tools
Safety Climate Survey **
Trigger tool **
Significant event analysis
Practices choose one

7. Safety Climate Survey Online Team centred Measurement Diagnosis
Catalyst for change
Measurement- against other practices. Prev surveys in same practice 7

9. Experience so far
913 GP Practices in Scotland used the survey annually for 3 years
Used by 60 Auckland GP Practices since 2014
Insights
Involvement
Discussion
Change

10. Insights
“Many of us in the team hadn’t really made the link that us failing to communicate was a threat to patient safety ….we had a lot of really good stuff come out of it, a lot of very open discussion” 10

11. 11

12. The Trigger Tool and GP Detecting and Reducing Harm in Primary Care Using a Structured Case Review ( Trigger Tool ) GP / Patient Safety Advisor 12

13. 13

14. 14

15. 15

16. 16

17. By screening a small sample of the records of high risk groups of patients, the team can detect and learn from ‘patient safety incidents’ that may be hidden in the records.
Changes Culture – Proactively looking !

18. Process Choose a group of patients Sample 25 records 3 month period
Look for triggers
Look for harm
Review Findings
Identify learning and actions

19. Summary
“Trigger review provides the GP team with important opportunities to identify patient safety incidents, individual and team learning needs and provide focus for improvement activity.”

20. Experience Quick Finding harm not previously identified
Focus for Improvement
Cultural change
Training and support 20

21. Common Findings Adverse drug reactions - ADRs Co – prescribing
Lack of follow-up
Not Monitoring drugs
Results handling
Missed referrals
Not detecting the deteriorating patient 21

22. “To err is human, to cover up is unforgivable and to fail to learn is inexcusable”
HDC
HQSC

23. How do you currently learn from adverse events /or excellent care
How do you decide what to review?
Who is involved ?
What questions do you ask ?
What do you do next?
How do you review progress?

24. Significant Event Analysis is a process that helps practices answer the following questions:
What happened and why?
What can we learn from what happened?
What needs to change?
Reduces the chance of harm recurring

25. All need reflection discussion and teamwork

26. Links to Cornerstone
Indicator There is an Effective Incident Management System – SEA / Trigger Tool
Indicator There is a culture of safety and teamwork in practice - Climate Survey

27. Decide which one you are going to learn about and use
Safety Climate Survey**
Trigger tool **
Significant event analysis
Go to the right workshop after the break !

28. QI Tool Session Breakout Rooms Significant Event Analysis
Trigger Tool
Kennedy - Lenihan Room
Significant Event Analysis
Phelan Room
Safety Climate Survey
Main Room
Back to main room afterwards