The following steps will help you identify what you can do to improve patient safety and comply with clinical governance and risk management requirements. Developing a practice system for identifying, analysing and tackling the causes of patient safety incidents will reduce the risk of incidents occurring.
Step one Build a safety culture
Step two Lead and support your staff
Step three Manage your risks
Step four Encourage reporting
Step five Involve and communicate with your patients
Step six Learn and share safety lessons
Step seven Implement solutions to prevent harm
One. A safety culture
No matter how careful people are with the work that they undertake, mistakes can happen. The best people sometimes make the worst mistakes. Encourage everyone in the practice to report incidents and near misses.
A patient safety incident cannot simply be linked to the actions of the individual involved; it is also linked to the system(s) in place within the practice. Looking at what failed in the system helps everyone to learn lessons that can prevent the incident recurring.
People will not report incidents if they believe they are going to place themselves or their colleagues at risk of being disciplined or punished. Establishing an open and fair environment will mean that:
staff are open about the incidents they have been involved in
everyone in the practice is accountable for their actions
everyone is able to talk to colleagues and superiors about any incident
the practice is open with patients when things have gone wrong and explain what lessons have been learnt
staff are treated fairly and supported when an incident happens.
Action:
Develop a practice policy to ensure everyone understands:
what is meant by a patient safety incident
what to do if an incident occurs
how to record incidents, investigate them fairly and discuss and implement the necessary action
to consider whether the patient, their family and the staff involved require support
the lessons that might be learnt from the incident.
Two. Lead and support your staff
Strong leadership and a commitment to best practice can improve patient safety. Ensure everyone takes patient safety seriously and when incidents occur, you listen and are supportive.
Action:
appoint someone to take responsibility for patient safety issues
discuss 'patient safety' at practice meetings as a regular agenda item. Encourage individuals to view the practice critically and ask questions and challenge a process or procedure if they feel something may affect patient safety. Follow up or give feedback from previous meetings
include patient safety in the induction training programme for new staff
build patient safety into practice training programmes for all staff and explain the benefits.
Three. Manage your risks
Patient safety incidents are not usually random occurrences or unpredictable events beyond control. Chance does play a part and human error can never be eliminated but the majority of incidents fall into systematic and recurrent patterns. Patient safety is an important aspect of risk management and you will need to identify things that could go wrong and develop systems to manage these potential risks. When carrying out your practice risk assessment, involve the relevant staff members – receptionists for the reception area and waiting room, dental nurses for the clinical areas and patient care aspects, for instance. They may see situations differently and be aware of potential risks that you might not consider.
Action:
consider patient safety when assessing clinical and non-clinical risks as part of your practice risk assessment
use information about reported incidents to improve patient care – check both the accident book and the complaints received to assess whether there are any incident patterns emerging
discuss what improvements or adjustments to existing systems can be made to reduce the possibility of a patient safety incident. Do any new systems need to be introduced?
assess the potential risk to individual patients in advance of treatment.
Four. Encourage reporting
Reporting patient safety incidents and prevented incidents nationally provides the opportunity to ensure that the learning gained from the experience of a patient in one part of the country is used to reduce the risk of something similar happening to future patients elsewhere. All reports entered onto the National Reporting and Learning System (NRLS) have the names of the patients and staff removed, together with other identifying data not required for the purposes of learning. Statistical analysis identifies themes, patterns and clusters.
Although national reporting is not yet common in dentistry, effective reporting systems within the practice will encourage team members to identify incidents which either caused or could have caused harm to a patient. As more incidents are reported, more information becomes available about what is going wrong and, consequently, more can be done to make the practice safer.
Reasons why people are hesitant to report incidents include:
sense of failure – everyone is trained to expect high standards of performance
fear of blame
fear of increased medico-legal risk
benefits of reporting are unclear – lack of acknowledgement and feedback, so no perceived positive results
lack of resources – no time to report and discuss the matter
'not my job' attitude
lack of understanding about what to report and when.
What, in your practice, might prove to be a barrier?
Action:
encourage staff to report all patient safety incidents, including those that were prevented
develop an in-house system for recording and analysing all incidents
report incidents locally via the PCT, LHB or nationally to the NRLS using the eForm.
Five. Involve and communicate with your patients
When something goes wrong, those who have been harmed want information about what has happened, and often want an apology. Patients often accept something has gone wrong when told about it promptly, fully and compassionately – honesty often minimises the trauma. Patients who feel they have not received an apology or an explanation are more likely to complain and seek compensation. Reassure patients and their families that the right lessons have been learnt from the incident.
Action:
ensure patients and their families are provided with clear, accurate and timely information when things have gone wrong and they have been harmed as a result. This should form part of your practice policy
make sure that patients and their families receive an immediate apology where it is due, and are dealt with in a respectful and sympathetic way
investigate the incident thoroughly
provide staff with the support, training and encouragement they need to be open with patients and their families.
Six. Learn and share safety lessons
It is important to report when things go wrong but it is equally important to look at the underlying causes of a patient safety incident and to prevent it happening again.
When a patient safety incident occurs, investigate how and why it occurred, rather than finding who is to blame (known as 'root cause analysis').
Action:
find out what happened, how and why – gather information
identify the chain of events leading up to the incident and why something went wrong
identify what changes are necessary to prevent incident happening again
share lessons from the analysis with the practice team
the NPSA tool kit can help with this and can be found at: www.npsa.nhs.uk/health/resources/root_cause_analysis/conditions
Seven. Implement solutions
When you have identified the causes of the incident and what changes are need to prevent it happening again, you need to ensure these solutions are put into place and understood by everyone in the practice. Simple changes are easier to implement than complicated ones and keeping the changes to a minimum will also help. You will also need to show that the change will make a difference and it will help individuals to do their jobs.
Action:
involve your team in developing ways to make patient care better and safer, which could include re-designing systems and processes, staff training or adapting clinical practice
assess the risks for any changes you plan to make
review with your team the impact of the changes
give staff with feedback on any follow-up reported incidents.
Link to Patient safety in dental practice advice note
