What went wrong and what we did
It remains important to us to act in a timely manner when something goes wrong. This part of the report shows the response we made in acting on some of these things and what we did about them following the reporting of an incident.
| What went wrong | What we did | What this means | |
|---|---|---|---|
| 1 | An increase in Serious Incident actions not being completed in a timely manner was identified. | Created an Action Setting Group meeting twice monthly to set the SI actions in an open forum. | Action holders and specialist managers will feel more involved in the Serious Incident process being able to suggest actions for the Trust to take and set timeframes for these. |
| 2 | A new Standard Loading List (SLL) was created to make all grab bags the same. This meant there was not enough equipment for effective cannulation in emergency situations. |
Staff were encouraged to report any issues with lack of appropriate equipment, this was also reported to the SLL working group. The cannulation kit was reviewed and the amount of equipment provided was amended. |
Staff will feel more confident that the equipment will be accessible when needed for a patient without having to return to the ambulance to get additional supplies. Bi-annual reviews will take place through our Clinical Best Practice Group (CBPG) and our Product Devices And Procurement Group (PDPG) to ensure correct equipment is purchased and placed on vehicles. |
| 3 | The ineffective breathing descriptor was not always being identified by all call handlers causing incorrect call prioritisations and delays to patients. |
An urgent safety notice was issued to all control room staff detailing the process needed when dealing with ineffective breathing descriptors. An amalgamated Serious Incident investigation was completed looking into five incidents. Further training was released to all call handlers. |
Patient’s symptoms will be more effectively identified and prioritised when calling for and emergency ambulance response. Call handlers will feel more confident in the process needed when handling a call with ineffective breathing descriptors. |