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 the number of delayed responses leading to patient harm was detected. | All relevant internal stakeholders built an organisational action plan to address the issue within EEAST's control.Worked with system partners to develop a framework to investigate delays as a healthcare system. | Changes were made to shifts patterns, to ensure adequate clinical staffing was available at the appropriate times.Developed a trajectory for the recruitment of call handlers and started this recruitment. |
| 2 | Several crews did not approach their patient due to there being a safety risk associated with them. This was identified to be due to a lack of training about dynamic risk assessment. | Developed and approved a training programme to improve staff's knowledge and understanding of dynamic risk assessment to be rolled out from May 2022. | Staff will feel more confident when approaching a patient with staff safety risks associated. They will be able to respond dynamically to a changing situation. |
| 3 | Several investigations highlighted that there were human factor elements associate with root causes. This means human behaviours, decision making and the conditions which affect human performance are central issues within our investigations. | Procured a suite of books which are available to our clinicians when they complete their mandatory training. Most have elements of human factors content. Committed to producing a suite of roller displays, focused on human factor considerations in healthcare. Provided online training to some clinicians about bias and latent conditions. | Staff will be more aware of the factors which impact on their performance. With awareness, they can consciously amend their behaviours, think more analytically and make safer decisions. |