Openness and learning following patient safety events
Research type
Research Study
Full title
Openness and Learning Joint Commission: Using patient experience for improvement following a patient safety event
IRAS ID
297720
Contact name
Jean McQueen
Contact email
Sponsor organisation
NHS Health Education for Scotland
Clinicaltrials.gov Identifier
N/A, N/A
Duration of Study in the UK
1 years, 0 months, 0 days
Research summary
Summary of Research
Typical of service users and families who are involved in patient safety incidents is the stated intent that they “don’t want anyone else to go through what they have experienced”. Inherent in this sentiment is the desire that services learn from feedback following safety incidents, complaints and near misses where unnecessary harm is caused. A range of existing review processes currently offer NHS Boards the opportunity for learning, improvement and quality assurance when things go wrong, and particularly when unintentional harm or death are the outcomes. Current guidance suggests health and care providers explain the incident, offer an apology, and a commitment to prevent recurrence. There is growing recognition among health care providers and policy makers that when things go wrong, the patient or their families should be heard and given the opportunity to participate in the incident investigation process (Kok et al 2018). We believe that involving patients, carers and relatives can support learning, reconciliation and prevention of future patient safety incidents. Guidance on how best to do this in a caring, compassionate and restorative manner is lacking. This study focuses on openness and learning following patient safety events and seeks to understand and learn what ‘good’ patient involvement in patient safety reviews should look like from those with lived experience. This study will last 12 months and involves NHS patients, their carers or relatives. We will explore via interview participants perceptions on their involvement in patient safety events. This will include their experience on the barriers and enablers to participation, communication, learning and opportunities for improvement. Information gained will be used to support the development of national guidance for Scotland on involving people in patient safety reviews.Summary of Results
This study illustrates what matters to patients and families using their suggestions to discuss improvement in practice. It adds detail on enacting this, with eight recommendations APICCTHS model (Apology, Person-centred, Inclusive, Communication, Closing the loop, Timing, Heart of Review, Support for staff). Findings suggest that an open, collaborative process includes an apology, asking patient and family preferences for involvement in the review, appropriate timing, person-centred compassionate communication, redressing the power imbalance, closing the loop by communicating the learning and what steps are being considered to help prevent recurrence and similar events happening to others. For the health service, not listening to the patient and their family risks missing vital learning which could improve patient safety and quality of care. Engaging patients and families in reviews and communicating in a compassionate manner could also decrease litigation claims. Personalised conversations, a streamlined review process, focused on the healthcare system and circumstances around the event with open engagement to enhance learning are what mattered most to our participants. For further details see https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fclick.pstmrk.it%2F3ts%2Fbmjopen.bmj.com%252Fcontent%252F12%252F5%252Fe060158.long%2FNBTI%2FCbG4AQ%2FAQ%2F759bcb08-c0d9-450f-8cd3-34ba8a1c23df%2F1%2FKgwE8k9xbX&data=05%7C02%7Capprovals%40hra.nhs.uk%7C9c8a72a6e4fb4a84deb808dcecf50d39%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C638645784431981814%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=kismMMlp5VxrIVLxsakrRaweMnnmrzEuJclDnBRGCwM%3D&reserved=0REC name
West of Scotland REC 1
REC reference
21/WS/0048
Date of REC Opinion
12 May 2021
REC opinion
Further Information Favourable Opinion