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News and presentations for today's Serious Incident Investigation & Learning conference

Improving Patient Safety: Changing the Culture
Deinniol Owens
, National Investigator, Healthcare Safety Investigation Branch

Deinniol is a qualified solicitor with a background in patient experience and investigations. He has investigated NHS complaints at the Parliamentary Health Service Ombudsman (PHSO) and was a patient experience manager at Sheffield Teaching Hospitals NHS Foundation Trust. Prior to HSIB, he was an inspector and inspection manager at the Care Quality Commission (CQC). Deinniol has an MSc in Healthcare Leadership and is currently studying for a further MSc in Patient Safety and Clinical Human Factors at The University of Edinburgh.

"Why aren’t we learning? How can we learn better? I think it's about changing culture. No blame should be attached to staff who make mistakes (Dr Bill Kirkup CBE) A mistake is an unintended act. Factors contributing to better investigation - training and resources. Family and staff engagement. Root cause  - look at system rather than individual. Human error - which is NEVER an end point of an investigation. Understanding 'Work is done'."

Full PowerPoint Presentation

Implementing the Serious Incident Framework in practice
Dr Hester Wain
, Deputy Director of Patient Safety and Risk, Royal Free London NHS Trust 

Hester has worked in the NHS for 15 years in both the provider and commissioning sectors.  She previously had a more academic career as a Senior Postdoctoral Research Fellow at University College London working on the Human Genome Project.

Her role is to inspire, motivate and influence multidisciplinary teams to help them develop quality improvement and patient safety within every aspect of healthcare, so that patients and staff can place their trust in the NHS not to harm them by errors of omission or commission.  With over 10 years’ experience using quality improvement science to implement and embed sustainable changes, Hester leads on Patient Safety Improvement.  She also leads serious incident investigation and management, and has direct practical knowledge of the challenges of root cause analysis in healthcare and familiarity with the impacts that this has on patients, their families and the staff involved. In 2018, Hester graduated with the Nye Bevan award from the NHS Leadership Academy.

"The national patient safety strategy is  - Insight, Involvement & Improvement. The vision is to continuously improve patient safety. We are trying to change the culture of the 6th biggest organisation in the world. We have made huge bounds but we've still got lots to learn from and improve on, in the future. Staff support is so important. Safety culture is something to think about - Just being rude or abrupt towards somebody can impact their day and then go on to impact patient safety. Accountability is doing the thing to make the change so it doesn’t happen again - You are the person who is going to deliver the change. Safety is about incident prevention' 'It's also about Learning from excellence - when things go right! World Patient Safety Day is on 17th September 2019. It's not about blame it's about understanding processes where we are not getting it right."

Full PowerPoint Presentation

Human Factors & Serious Incident Investigation
Mr Khosrow Sehat
, Consultant Trauma & Orthopaedic Surgeon, Nottingham University Hospital NHS Trust 

Pre-event abstract
In this presentation, we will review the history of human factors engineering in aviation which led to the discipline of human factors psychology and subsequently its application to healthcare systems.

This is the study of the interaction between human intuition or predictable human conduct and the equipment or process that is being used by the individual.
An understanding of human factors psychology is useful for risk management and prevention of error. Many hospitals now have training labs with simulations to prepare staff for low frequency, high risk scenarios and reduce the risk of error. The intention is to anticipate the mistakes that could potentially occur and install preventive systems, behaviour and skill. 

Following adverse events, investigation should include an examination of human factors that either contributed to or failed to prevent the error or adverse event. Recommendations arising from the investigation may include modifications to the environment, equipment design, process, procedure or training requirements.

Most importantly, working with consideration for human factors psychology and human fallibility is a departure from the traditional healthcare environment and a transition to a more methodical and objective mind-set. The use of checklists is a basic example. However, implementation of this culture change meets resistance and requires a review of hierarchy and communication. Framing the investigation recommendations in an appropriately technical and emotionally detached manner can attract support and its uptake. 

"The following causes of human error I call the dirty dozen -  Poor communication, Complacency, Lack of Knowledge, Distraction Lack of team work, Fatigue, Lack of resources, Pressure, Lack of assertiveness, Stress, Lack of awareness, Norms. The most important part of an incident is the debrief - if we don't discuss what went wrong we can't make sure it doesn't happen again. We want to look out for things that work well - it's not just about what went wrong."

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