Patient safety 3 - How do we improve how we learn from harm?
01/24/24 • 52 min
It is not enough just to collect data on harm occurring to children in healthcare settings. We need the data to be robust, comparable across the NHS and for it to be transformed into effective, meaningful changes in outcome.
In episode 3 of our series on paediatric patient safety, we speak with Dr Damian Roland, a paediatric emergency medicine clinician scientist and head of service for the Children's Emergency Department at Leicester Royal Infirmary.
As Damian discusses on the podcast, in order to learn from harm and prevent it occurring again we need to collect data and investigate what is occurring across the healthcare system rather than looking to individuals. Removing the individual, more punitive approach to harm investigations could improve the quality of how we record and report harm.
There is already a wealth of learning available from a range of sources including national reports, coroner’s findings described in regulation 28 reports to prevent future death and large-scale reviews like those of the Health Services Safety Investigations Body. We can investigate whether the causes of harm identified in these reports are occurring where we work and make proactive steps to avert it.
Damian also shares the progress of the SPOT programme (System-wide Paediatric Observation Tracking). This looks to reduce harm and improve how we learn from harm by creating a standardised common language to identify and discuss children whose health is deteriorating.
Thank you for listening.
Hosted by Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement | Produced by 18Sixty
Please be advised that this series contains stories relating to child death and harm. All views, thoughts and opinions expressed in this podcast series belong to the guests and not necessarily to their employer, linked organisations or RCPCH.
About the Patient Safety series
As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings. We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.
The RCPCH Patient Safety Portal at https://safety.rcpch.ac.uk has lots of resources. It includes a wealth of information summarising reports and investigations that identify what puts children at risk of harm. It is imperative to turn this knowledge into action through improvement activities.
More about Dr Damian Roland
Damian is a paediatric emergency medicine clinician scientist and is head of service for the Children's Emergency Department at Leicester Royal Infirmary. Among his many achievements, Damian has been focused on addressing the challenges of identifying deterioration in health in children. He created the Paediatric Observation Priority Score for Children's Emergency Care and currently he is instrumental in the NHS England SPOT programme.
Topics/organisations/papers referenced in this episode
- John Madar (PDF)
- Datix
- Health Services Safety Investigations Body
- Royal College of Emergency Medicine
- Royal College of Paediatrics and Child Health
- René Amalberti
- Adrian Plunkett
- Learning from Excellence
- David Sinton (on X)
- POPS (Paediatric Observation Priority Score for Children’s Emergency Care) - (PDF)
- Swiss Cheese Model (on National Library for Medicine)
- NHSE SPOT: System-wide Paediatric Observation Tracking programme - guidance<...
It is not enough just to collect data on harm occurring to children in healthcare settings. We need the data to be robust, comparable across the NHS and for it to be transformed into effective, meaningful changes in outcome.
In episode 3 of our series on paediatric patient safety, we speak with Dr Damian Roland, a paediatric emergency medicine clinician scientist and head of service for the Children's Emergency Department at Leicester Royal Infirmary.
As Damian discusses on the podcast, in order to learn from harm and prevent it occurring again we need to collect data and investigate what is occurring across the healthcare system rather than looking to individuals. Removing the individual, more punitive approach to harm investigations could improve the quality of how we record and report harm.
There is already a wealth of learning available from a range of sources including national reports, coroner’s findings described in regulation 28 reports to prevent future death and large-scale reviews like those of the Health Services Safety Investigations Body. We can investigate whether the causes of harm identified in these reports are occurring where we work and make proactive steps to avert it.
Damian also shares the progress of the SPOT programme (System-wide Paediatric Observation Tracking). This looks to reduce harm and improve how we learn from harm by creating a standardised common language to identify and discuss children whose health is deteriorating.
Thank you for listening.
Hosted by Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement | Produced by 18Sixty
Please be advised that this series contains stories relating to child death and harm. All views, thoughts and opinions expressed in this podcast series belong to the guests and not necessarily to their employer, linked organisations or RCPCH.
About the Patient Safety series
As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings. We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.
The RCPCH Patient Safety Portal at https://safety.rcpch.ac.uk has lots of resources. It includes a wealth of information summarising reports and investigations that identify what puts children at risk of harm. It is imperative to turn this knowledge into action through improvement activities.
More about Dr Damian Roland
Damian is a paediatric emergency medicine clinician scientist and is head of service for the Children's Emergency Department at Leicester Royal Infirmary. Among his many achievements, Damian has been focused on addressing the challenges of identifying deterioration in health in children. He created the Paediatric Observation Priority Score for Children's Emergency Care and currently he is instrumental in the NHS England SPOT programme.
Topics/organisations/papers referenced in this episode
- John Madar (PDF)
- Datix
- Health Services Safety Investigations Body
- Royal College of Emergency Medicine
- Royal College of Paediatrics and Child Health
- René Amalberti
- Adrian Plunkett
- Learning from Excellence
- David Sinton (on X)
- POPS (Paediatric Observation Priority Score for Children’s Emergency Care) - (PDF)
- Swiss Cheese Model (on National Library for Medicine)
- NHSE SPOT: System-wide Paediatric Observation Tracking programme - guidance<...
Previous Episode
Patient safety 2 - If we are psychologically safe, children are safer in our care
Psychological safety in healthcare settings is the condition in which you feel included, safe to learn, safe to contribute and safe to challenge the status quo - without fear of being embarrassed, marginalised or punished. And it's an essential foundation in building a safety culture.
Individually, feeling psychologically safe improves performance and innovation, while feeling unsafe reduces productivity and harms retention. In a highly productive team, it is about feeling safe to take risks, to learn from each other and to feel resilient and able to tackle the difficult and varying challenges of healthcare with a healthy mindset.
This is the second episode in our patient safety series and features Dr Dal Hothi and Dr Jess Morgan. Learn how you can reflect on your own behaviour, champion effective communication and create a psychologically safe space within your team.
Hosts: Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber, RCPCH Head of Quality Improvement
Produced by 18Sixty
Please be advised that this podcast series contains stories relating to child death and harm. All views, thoughts and opinions expressed belong to the guests and not necessarily to their employer, linked organisations or RCPCH.
If you are a healthcare professional and you are worried that you are suffering with burnout please speak to your team, your GP or Practitioner Health.
About the speakers
Dr Dal Hothi is a paediatric nephrologist at Great Ormond Street Hospital. She's also a Director of Leadership Development at the Faculty of Medical Leadership and Management, as well as being an Officer for Lifelong Careers at the RCPCH.
Dr Jess Morgan is a paediatric doctor and Dinwoodie RCPCH Fellow who leads on the RCPCH Thrive Paediatrics Project along with Dal.
About the patient safety podcast series
As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings.
We hope you will be entertained, educated, and energised to make strides in improving the safety of the children that you care for.
To learn more, visit the RCPCH Patient Safety Portal and begin your journey in improving your own psychological safety and that of those you work with.
Links for topics/organisations/papers referenced in this episode
- Dinwoodie
- Thrive Paediatrics at RCPCH
- Amy Edmondson and psychological safety
- Tim Clark’s four stage model of psychological safety
- Freedom to Speak Up (The National Guardian)
- Charles Vincent ("Safety is not defined by the absence of negative outcomes") - The Health Foundation: The measurement and monitoring of safety
Next Episode
Patient safety 4 - Involving children, young people and their families in making healthcare safer
It is imperative that children and young people are central to the co-design and co-production of our patient safety improvement interventions.
In this episode, we speak with Dr Jane Runnacles, consultant paediatrician at St. George's Hospital, and Dr Victoria Dublon, paediatric diabetes consultant at the Royal Free Hospital. Both are champions of improvement work that puts the young person and their needs first.
As Jane and Victoria describe, involving children, young people and their families in improvement work improves the experience and outcome for all involved. There are fantastic examples of co-creating and co-producing safety improvements in healthcare.
We discuss the practicalities of how to do this and who to involve in your healthcare setting, and we hear about some of Jane and Victoria’s successes.
Thank you for listening.
Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement Produced by 18Sixty
Please be advised that this podcast series contains stories relating to child death and harm. All views, thoughts and opinions expressed belong to the guests and not necessarily to their employer, linked organisations or RCPCH.
About the patient safety series
As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings.
We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.
The RCPCH Patient Safety Portal has lots of resources. And our engaging children and young people web pages can help you get started on your engagement journey to effectively work with children and young people to improve their healthcare.
Dr Victoria Dublon is based at the Royal Free Hospital and part of the Trust-wide diabetes team. She has been a paediatric diabetes consultant for eight years, working primarily at the Royal Free Hospital as well as running clinics at Barnet Hospital and Chase Farm Hospital. As a registrar, she trained in adolescent health as well as endocrinology and diabetes and this continues to be a big part of her work. Victoria is involved in improvement work within the department as well as being a champion of ‘Me First’, striving to put the young person and their needs first.
Dr Jane Runnacles is a consultant in ambulatory paediatrics at St George's hospital NHS Foundation Trust, London and clinical governance lead for her department. She has an interest in acute paediatrics, simulation and quality improvement. During her postgraduate training in London, she was awarded distinction in her MA in clinical education and spent a year as a Darzi clinical leadership fellow at Great Ormond Street Hospital. Jane is a Training Programme Director for the London School of Paediatrics and leads their leadership and QI education programmes.
Topics/organisations/papers referenced in this episode
- Great Ormond Street Hospital
- Royal Free Hospital
- Darzi Fellowship
- Peter Lachman
- RCPCH SAFE Collaborative
- RCPCH QI Central
- Don Berwick
- Whiteboard communication project (on QI Central)
- Yincent Tse
- NHS blog - Asking "What Matters To You?"
- NHS - Co-production
- Paediatric Early Warning System (PEWS)
- St George's Hospital
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