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Doctors in training leading quality improvement: Families reporting critical incidents and near misses in a children’s hospital.

The project aimed to identify a method for families to report potential harm/near misses, decreasing the possibility of adverse events.

The problem

The determination of harm occurring in hospitals is not really known. Voluntary reporting methods are biased by differences in understanding what constitutes harm and a focus on serious events. Under-reporting of adverse events and harm is common practice. It has been reported that 10% of UK adult patients admitted to hospital experienced harm, half of which were judged to be preventable. In paediatrics, reported harm in UK hospitals, detected by the Paediatric Trigger Tool, is 14%. Patient-reported harm is different from that reported by clinicians. Further, we believe that patients/ families are witness to harm not seen by health professionals.

Aims
  • To build a simple, user-friendly system that would allow us access to the patient and their family’s perception of ‘harm’.

  • To alter the clinical staff ’s perception of what constitutes harm and how best to manage risk or harm at the front line.

Making the case for change

Stakeholder involvement was secured by consulting the risk and complaints team, PALS, medical staff, senior executives and patient forums including the Young Persons’ Forum. A parent was an active and equal member of the project’s planning and operational groups. The project manager was independent and external to the ward. We developed an escalation policy for the reporting system to align it with in-house governance and safeguarding structures. We designed and tested an information sheet to accompany the written consent form.

Your improvement

We tested the application of Family Questionnaire on a Paediatric Nephrology ward. Based on the findings, we designed a patient-centred reporting tool over a series of PDSAs, involving patients/ staff, and tested its usability. We implemented it on a cohort of patient - then on the entire ward.

 

Patients and families preferred the reporting tool over the questionnaire. 33 new safety concerns were raised; only 3% of these were matched by staff, indicating that families added new insight into safety issues. Communication problems (31%) and medication errors (21%) ranked highest on the list of concerns raised by families and patients.

 

Learning and next steps

The introduction of a simple, real-time bedside reporting tool and risk management process facilitated active engagement with families and patients, and the opportunity for disclosure and learning for staff. The challenge might be families feeling vulnerable to report problems of safety to staff. We are exploring the use of a volunteer as a dedicated, independent point of contact. The next step is to implement the tool in a wider setting. We recommend that units consider ways to move from a reactive approach once harm has occurred, to a proactive assessment using the real experts, the patients and their families.

Quality assurance/MHRA Registration

The project's idea of families helping to detect and manage adverse events is being continued and incorporated into current improvement strategies at the trust. The project had support and approval from the trust executives.