Patient Safety
Patient safety annual report 2021/22
Over the last year we refreshed our approach which emphasised a more proactive approach to improving 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 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
The safety framework is based around engagement. The framework provides a structure for locality leadership teams working collaboratively with the Trust’s safety team to deliver all aspect of clinical quality, including risk management, incident and complaint handling, and just culture. The support services and operational teams are now working closer than ever before for the benefit of patients and learn from when things go right as well as from when things don’t quite go to plan.
Incident reporting remained high, suggesting that the Trust has a good culture of reporting incidents. Reassuringly, most patient safety incidents reported resulted in no harm to the patient.
Serious incidents
There was a 400% increase in serious incidents declared during 2021-2022 compared with the previous year. This was mainly due to the sustained operational pressures across the health and social care system, leading to increased response times to our patients. We developed an action plan to improve all elements which contributed to response delays within our control. A key aspect of the action plan was to continue the close working relationship between EEAST and its system partners. One outcome of this collaborative approach was the development of a framework for the system to investigate such incidents together, rather than separately, allowing for an end-to-end review of a patient’s care. The key themes of serious incident were as follows, with a comparison to previous years:
| 2021/22 | 2020/21 | 2019/20 | |
|---|---|---|---|
| Delay | 114 | 9 | 13 |
| ECAT / AOC | 8 | 1 | 8 |
| Patient Injury | 8 | 5 | 4 |
| Clinical Treatment | 11 | 5 | 9 |
| Non-Conveyance | 17 | 18 | 13 |
| Equipment Failure | 1 | 0 | 1 |
| Other | 2 | 0 | 3 |
| Total | 161 | 40 | 55 |
With the commitment to treat more patients in the community, an important piece of learning from a thematic review of non-conveyance serious incidents, was the introduction of a non-conveyance care bundle. This is designed to improve the safety of patients who are discharged fromEEAST’s care to another part of the healthcare system. It provided colleagues with a standard of care to deliver to patients where previously there was none. We developed an electronic auditing tool to sit alongside the care bundle which allowed continuous monitoring of its use and identify focused
areas of improvement to further improve the safety and experience of patients not needing hospital treatment.
Duty of Candour
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 the statutory requirements.
|
|
2021/22 |
2020/21 |
2019/20 |
|---|---|---|---|
|
Number of cases initially requiring Duty of Candour |
161 |
40 |
55 |
|
Duty of Candour discharged |
161 |
35 |
50 |
|
Average timeframe for Duty of Candour to occur (working days) |
4.5 |
2.0 |
4.4 |
|
Average timeframe for letter follow-up (working days) |
1.7 |
2.6 |
1.2 |
67 colleagues received training relating to the organisational Duty of Candour as well as their professional Duty.
The NHS set key priorities for delivery within the national patient safety strategy.
Patient Safety Specialists
All NHS trusts are required to have at least one patient safety specialist. EEAST appointed five to demonstrate its commitment to improving the safety of its patients.
Patient Safety Syllabus
All Trust colleagues are required to complete the first module of the syllabus. A plan was developed to ensure that this will be delivered over the next 12 months.
Patient Safety Incident Response Framework
The early adopter sites have now evaluated the new patient safety framework for investigating when things don’t go to plan. EEAST worked with local and national partners to have a plan in place for when the full migration occurs from June 2022.