Patient Safety
Over the last year, we refreshed our approach, taking a more proactive stance in terms of improving patient safety.
The introduction of a safety framework supported locality leadership teams to deliver elements of clinical quality and safety performance.
The Trust continued to investigate serious incidents (SI) and identified learning from every investigation undertaken. Work towards delivering the national patient safety strategy continued, patients can expect a continually improving and safer service in the years to come.
Safety framework
Patient safety is about more than measuring how many incidents are reported, it includes engaging with patients, carers, family members and professional colleagues to use their lived experience as an opportunity to learn and improve services. It is about encouraging colleagues to be honest and open, by providing a supportive environment where a just culture can thrive.
Incident reporting remained high last year, suggesting that the Trust had a good culture of reporting incidents. Reassuringly, most patient safety incidents reported resulted in no harm to the patient.
Serious incidents (SIs)
There was a significant increase in serious incidents declared during 2022/23, compared with the previous year. Whilst this could be partly attributed to sustained operational pressures leading to increased response times to our patients, it was reflective of our level of scrutiny and openness when reviewing incidents. We continued to use the action plan to improve the elements which were identified through the scrutiny process.
The key themes of serious incidents were as follows, with a comparison to previous years:
| 2022/23 | 2021/22 | 2020/21 | 2019/20 | |
|---|---|---|---|---|
| Delay | 214 | 114 | 9 | 13 |
| ECAT / EOC | 12 | 8 | 1 | 8 |
| Patient injury | 3 | 8 | 5 | 4 |
| Clinical treatment | 18 | 11 | 5 | 9 |
| Non-conveyance | 21 | 17 | 18 | 13 |
| Other | 10 | 3 | 0 | 4 |
In order to ensure that actions agreed following serious incident reviews followed the SMART process, an action setting group was established in early 2023.
Although still evolving, this group enabled operational teams to meet with the central team to develop and agree actions from serious incidents, which were achievable and realistic. It enabled the team to more easily follow up actions, confirm completion, and review the impact. There was an improvement in the number of actions closed or completed and the engagement with operational teams enabled them to appreciate the importance of learning from incidents.
The team used the patient safety incident investigation methodology to review groups of incidents when clusters emerged in advance of the national Patient Safety Incident Response Framework (PSIRF) planned for September 2023.
Duty of Candour (DoC)
NHS Trusts have a statutory duty to inform and involve patients and their families in investigations where there has been severe harm, under Regulation 20 of the Health and Social Care Act. The Trust continued to perform well against this statutory requirement.
The increased number of DoC cases last year correlated with the increased number of serious incidents reported. Despite this increase in the number discharged, the time for carrying out the DoC call, and sending the subsequent letter had improved, compared with previous years. This can be attributed to the sustained work by the patient safety team, with input from local managers.
| 2022/23 | 2021/22 | 2020/21 | 2019/20 | |
|---|---|---|---|---|
| Number of cases initially requiring Duty of Candour (DoC) | 272 | 161 | 40 | 55 |
| Duty of Candour discharged | 272 | 161 | 35 | 50 |
| Average timeframe for Duty of Candour to occur (working days) | 4.0 | 4.5 | 2.0 | 4.4 |
| Average timeframe for letter follow-up (working days) | 1.0 | 1.7 | 2.6 | 1.2 |
The NHS set key priorities for delivery within the national patient safety strategy.
Patient safety specialists
EEAST has six patient safety specialists and agreed funding for two more posts. This enabled us to assign a patient safety specialist to each business unit providing expertise and links with other providers within local systems.
Patient safety syllabus
All Trust colleagues were encouraged to complete the first module of the syllabus.
Patient Safety Incident Response Framework (PSIRF)
PSIRF will be implemented fully from September 2023, EEAST identified the importance of getting the implementation right and appointed a PSIRF lead. Mandatory requirements of the patient safety syllabus are planned.