As one of the largest teaching trusts in the UK, University College London Hospitals NHS Foundation Trust (UCLH) is committed to delivering top quality patient care, excellent education and world class research across its six London hospitals. To manage incident reporting and patient service delivery the Trust has recently implemented Datix’s web-based patient safety and risk management software application.
In the first three months of the system being in use, the Trust has noted a 50% fall in the number of serious incidents. Datix has enabled management teams to identify patterns and put in place risk mitigation and learning plans to improve patient care and safety.
The implementation followed eighteen months of careful planning and preparation, to ensure that induction and training were undertaken by all staff who would be using the system from the first day it was put into effect.
According to Mark Hall, Trust Risk Manager at UCLH, “We wanted to replace our paper based system of recording incidents to have a solution that was accessible on the web, to improve both access and control for those recording incident data and to ensure patient confidentiality.”
The previous system of collating manual records in the risk management department was time consuming and open to error, with forms being lost, illegible, or with photographs and statements becoming detached and possibly breaching the security of patient records.
Having spoken with eleven other Trusts on their adoption of new systems, Hall and his team identified the possibility that there may be a drop in incident reporting when the solution went live, due to resistance to a new system and lack of training.
As a result the UCLH team developed a thorough induction programme for key ‘handlers’ in each location prior to implementation, with considerable success. Mark Hall explained, “We launched Datix on a Monday, having installed it the previous Friday and found that there were already several incidents reported by early Monday morning.
For the past seven years the Trust has reported 5,000 incidents a year consistently – in just the first three months of using Datix we recorded approximately 44% of that number, which is a phenomenal success.”
Reporting to the National Patient Safety Agency (NPSA) has also become much easier and faster, Hall said, “We used to report weekly, now we can upload daily knowing that the data is up to date and the reporting can go directly to the NPSA.”
"We launched Datix on a Monday, having installed it the previous Friday and found that there were already several incidents reported by early Monday morning." Mark Hall, Trust Risk Manager at UCLH
All of the data supports the Risk Register and Assurance Framework. The risk management team identifies patient trends and forwards reports to specific divisional groups in the Trust. Monthly risk reports are sent out to the divisions that enable the managers to drill down and create their own reports - such as the Falls Group or Tissue Viability nurses. Reports are also sent to the Patient Safety Steering Risk Committee and the Executive Board.
Managing incidents directly within the divisions and within a faster time frame has helped to identify where mitigation work is required.
Communication plays an important part in the risk management process at UCLH. The team made a conscious decision not to use email to communicate and manage incident reports, but to make face to face communication part of the process. The risk department produces the reports, but if, for example, an incident noted on the ward is related to an action that happened in the theatre or laboratory, the person completing the report, on the ward is required to speak directly to the other department involved.
While the overall successful reduction of serious incidents across the Trust cannot be directly attributed to Datix, it has, according to Mark Hall, played a significant part. “We have noted that while the reporting of incidents has increased due to easy access to the system, the number of serious incidents has reduced by 50%, which is exactly the risk profile that we would want to see.
We are transforming care at the bedside and in wards with many new initiatives, working closely with the communications department to look at what’s new and using our findings from Datix to effectively introduce changes.”
The team has also been able to use the enhanced reporting capability in the system from the Claims, Complaints and Patient Experience (PALS) module, identifying more accurately where the claims and complaints are coming from.