Lessons Learned Newsletter

Lessons Learned Newsletter In this Issue PAGE ♦ PALS 2-3 February 2009 - Issue 8 Welcome Welcome to the 8th Edition of Greater Manchester West Mental Health NHS Foundation Trust’s Lessons Learned Newsletter. As well as the usual updates on Datix, PALS and Medication Incidents, this issue also contains information on how the Police apply for access to individual health records and Dr. Colgan’s case book on Record Keeping. 'In-appropriate or Un-authorised Access to Patient Records' 7-8 Update ♦ Lessons Learned 4 from Serious Incidents ♦ Police 5-6 Applications to Health Records ♦ DATIX Update ♦ Complaints 9 9 10-11 Update ♦ Dr. Colgan’s All incidents of in-appropriate or un-authorised access to patient records either on ICIS or with paper records MUST be reported to the Trusts' Integrated Governance department via the same process as other serious incidents as per the Trust's Incident Reporting Policy. If there is a concern that there has been in-appropriate or un-authorised access to a patients ICIS record then the ICIS team can be sent an request in writing from Service managers for a print out of specific audit logs of patient records. If a service has identified that there has been in-appropriate or Un-authorised access, then an Incident and Near Miss Reporting Form must be completed asap and forwarded onto sui@gmw.nhs.uk. Casebook ♦ Ten Commandments of Records Keeping ♦ Medication 12 Errors GMW has a Positive Safety Reporting Culture! NPSA Chief Executive Martin Fletcher said; "Organisations with a high rate of reporting are usually organisations where there's a strong commitment to patient safety.” The NPSA leads and contributes to improved safe patient care by informing, supporting and influencing the health sector. They are an Arm’s Length Body of the Department of Health. Want to find out more about the NPSA? http://www.npsa.nhs.uk/corporate/about-us. The latest organisational feedback report from the NPSA records the fact that due to the efforts of staff, GMW has a very positive safety reporting culture: • GMW incident reporting rate is higher than most other mental health & learning disability Trust rates. This is great, keep reporting ! • 76% of GMW incidents do not result in harm, which is great! We want to continually increase the amount of reports but reduce the severity of them over time. • GMW reporting time is less than half that of other Trusts within its group. So keep reporting incidents as soon as they occur! A big thank you to all staff whom continue to report incidents of all types to the Integrated Governance team. Your actions help to improve patient safety by reducing the likelihood of re-occurrence and improving patient care. Thanks a lot from the Integrated Governance Team. David Pilsbury, Deputy Director of Integrated Governance PAGE 1 Lessons Learned Newsletter - February 2009 Issue 8 Patient and Advice Liaison Service (PALS) Update Numbers and types of enquiries from October 2008 to January 2009 35 30 Making a comment 25 Deal with problem Information about NHS Make a suggestion Register concern 10 Signposting to specialist service 5 20 15 0 2008 10 2008 11 2008 12 2009 01 (1) Lessons Learned From PALS Enquiries Selected enquiries dealt with by PALS that may have relevance for other services throughout the Trust. ♦ Issues about Information Service users have contacted PALS a number of times about information available in inpatient areas and bedrooms. Problems include information about how wards work, who care coordinators and named nurses are, services available in the community and peoples’ rights whilst staying as inpatients in our services. Recommendation: All Matrons and ward managers should routinely check that information packs about services are made available to people after admission to inpatient services. Information about patient rights, activities and services in the community should be displayed clearly and posters should not prevent other information being viewed. New PALS and Patients’ Rights posters and leaflets are now available for all Services across the Trust. Contact PALS for copies of these. …..continued overleaf PAGE 2 Lessons Learned Newsletter - February 2009 Issue 8 PAGE 3 Patient and Advice Liaison Service (PALS) Update Continued…. (2) Lessons Learned e From PALS Enquiries of the main issues raised other relevant information have within the Lessons Learned not occurred. section of incident reviews we have been receiving in the Governance Department is to Carers and emphasise the extreme importance of timely and accurate Confidentiality It is imperative that significant recording of all actions relating A number of carers have information relayed during disto contacted PALS concerned the treatment and care of cussions with patients and their patients by all staff (Clinical and that staff are not prepared to relatives is recorded in the paNon-Clinical). Good practice in share any information about tient notes as soon as is practirelation to record keeping their relatives and those becably possible, especially if the should confirm to the reader ing cared for. patient is at risk and may go on that the information is correct. If to harm themselves. There there is no documentary eviRecommendation: We need to be clear about have been instances whereby dence the reader should be whatassume that can be given to recalled in and Team information staff have enquirers the able to correctly what can not. In the majority of circumstances the Management Review, that the review, consultation, medienquirers can patient or relatives have cation amendments or any be given some information,given however the amount of information depends on consent and circumstances. PALS has electronic copies of the leaflet: ‘Carers and Confidentiality’ which helps guide both carers and workers through specific aspects of confidentiality, a must read for anyone delivering inpatient or community mental health services. (3) Lessons Learned From PALS Enquiries Better Arrangements Needed for Meeting Dietary Requirements of Diabetics There have been a number of suggestions that there should be more consideration made for the dietary requirements for diabetics including more choice at meal times, and more diabetic products such as hot chocolate. Recommendation: Increasing numbers of people are becoming diabetic in the UK. Managers should consider the dietary requirements of diabetics and ensure there is adequate choice at meal times and also provisions in services kitchens. PAGE 3 Lessons Learned Newsletter - February 2009 Issue 8 PAGE 4 Lessons Learned from Serious Incidents SCENARIO 1 A Team Management Review (TMR) was held regarding a patient with a history of violent and aggressive behaviours. As a result of the TMR it became apparent that there were discrepancy’s regarding the patients CPA, incidents not being reported to Integrated Governance, Risk Assessments, Care-co-ordinator and CRHT follow up. Lessons Learned ♦ A programme on up to date care plan training to be devised. ♦ Ward Managers to address care planning with individual staff in line management supervision. ♦ Importance of up to date risk assessments and management plans to be emphasised to staff members. ♦ Review of the current transfer meeting with clear terms of reference and formal agenda. ♦ All care co-ordinators to attend ward reviews and to evidence their attempt to visit service users on ICIS records. ♦ All ward staff to document any contact made with care co-ordinators in ICIS. SCENARIO 2 Razor blades were discovered in a patients room who had a reported suicide attempt prior to his admission and who had on-going suicidal intentions. This discovery was made by the ward housekeeper and reported to staff. This however was not reported as an incident and there is no further reference to it by ward staff in the patients’ ICIS records. A few weeks later the same patient was found conscious in his room following a suicide attempt. Lessons Learned ♦ All incidents on ward to be reported in a full and timely way before staff go off duty. ♦ All patient related information communicated to staff on the ward to be recorded by ward staff on ICIS. ♦ Quality of risk assessments and discharge summaries on the ward to be routinely audited. ♦ All adult inpatient clinical teams at Meadowbrook to be made aware of this incident and the lessons to be learned. ♦ This incident has stressed the importance of communicating effectively any potential risk issues a patient might have with house keepers. PAGE 4 Lessons Learned Newsletter - February 2009 Issue 8 Police Applications to Health Records Consent “Usually” Required The Police regularly apply for access to health records of individuals in order to help with their enquiries, and for other reasons. However, under the Law, the Trust must still comply with the Data Protection Act, and unless there are exceptional circumstances, information on Patients is not given to the Police without Patient consent. This is usually done on a case-by-case basis, but just because the Police are making an application to see a health record, it does not mean that they are granted access as a matter of course. “Exceptional” Circumstances - The Wider Public Interest Where the Police have made an application (via your Directorate Subject Access Co-ordinator) to see the health record of a Patient, the Patient must be asked to give their consent before the application continues. As with applications by Solicitors, this can often take the form of a form of authority or statement where the Patient gives their consent. In some cases, the Patient will refuse consent for their health record to be accessed. When this occurs, the application is then judged on whether exceptional circumstances apply, where the health record is disclosed despite the Patient not consenting to this. In circumstances where consent is not given, it is decided whether or not it is in the wider public interest by the appropriate health professional (most commonly the Consultant of the Patient). They consider this question: “Does the wider public interest outweigh our responsibility in maintaining confidentiality?” If the Consultant decides that it is within the wider public interest to disclose the information without the Patient’s consent, then the health record could be disclosed to the Police (following the Police completing a form DP7). To assist you with this process please refer any Police enquiries to the Integrated Governance Department and ask for Mike Hulmes (Local Security Management Specialist) and/or Julie Bodnarec (Assistant Director of Clinical Governance). Please see overleaf for further information on this subject. PAGE 5 Lessons Learned Newsletter - February 2009 PAGE 6 Police Applications to Health Records Continued……. “Serious Arrestable Offences” Health records will be disclosed to the Police if it is for the purposes of the prevention or detection of a serious crime. Disclosing the records could be justified in order to protect the public. However, serious crime is a particular term that obviously does not apply to all Police enquiries. Police & Criminal Evidence Act 1984 The Police and Criminal Evidence Act 1984 defines what is categorised as a “serious arrestable offence”. Examples of these offences Treason, Murder, Manslaughter, Rape, Kidnapping, Certain sexual offences, Certain firearm offences, Hostage taking, Hijacking, Torture, Causing death by dangerous driving, Causing death by careless driving when under the influence of drink or drugs, Offences under the Prevention of Terrorism legislation, Making a threat which, if carried out, would be likely to lead to serious threat to the security of the state or to public order, Serious interference with the administration of justice or with the investigation of an offence, Death or serious injury of any person, Substantial financial gain or serious financial loss to any person. In these instances, when the Police make an application for a health record for the purposes and prevention of a serious crime, a Police Form DP7 should be provided, signed by an Officer not below the rank of Inspector (this form may vary between Police forces). However, the Trust itself must be satisfied that the matter in question does involve a serious crime before the application goes any further. A form being supplied may not be enough! In some cases, the Trust may also seek legal advice about the issue For further information on the above or anything else related to security issues please contact Mike Hulmes Tel: (0161) 772 4309 or Email: Michael.hulmes@gmw.nhs.uk PAGE 6 Lessons Learned Newsletter - February 2009 Issue 8 Datix Update Incident Module Goes Live in Young Persons Directorate The training phase for staff in the YPD is now complete and the protocol for the use of the Datix Incidents module has been signed off. The Directorate commenced the live pilot of the Datix incidents module on 26th January 2009. Three levels of staff are now using the Datix incidents modules: DIF1 Users - Any member of staff can report an incident or accident via the DIF1 Incident form accessible on the intranet (PILOT Sites ONLY) ICIS Link Persons - Qualified Nurses, who have been given specific training and who are on duty at the time the incident is recorded in Datix, to ensure a smooth and speedy transition into the patient ICIS clinical record. DIF2 Managers - Ward Manager/Matron etc, who are responsible for managing the incidents through the various processes, confirming whether or not a TMR is required and signing off the incident for approval by Governance DIF3 in line with the Trust’s Incident Management Policy. Training for the Adult Forensic Service will be starting 9th March 2009. The simultaneous roll out of training for Datix Incidents for Adult District Services across Bolton, Salford and Trafford is planned to start in April/May 2009 once the AFS has gone live. See incident Web Roll-out plan for further information. Updated Incident Web Roll-out Plan User Guides Available for Users New and revised versions of Datix User Guides are available for downloading on the Intranet Home page via the “Datix User Guides” link. This resource is frequently updated by the Datix Team and includes a range of electronic guides and support media .. Datix Web Incidents Roll-Out More Directorates Using Datix SABS Module Young Persons Directorate, Adult Forensic and Trafford Directorate have recently gone live with SABS on Datix. Other Directorates are due to go live in the coming weeks once training has been completed and their local SABS protocols are signed off. The Integrated Governance Department have been closely monitoring those Directorates/Services already using the Datix Safety Alerts (SABS) Module to ensure the designated “For Action By” users are correctly cascading and responding in line with the agreed local protocols. …..continued overleaf PAGE 7 Lessons Learned Newsletter - February 2009 Issue 8 PAGE 8 Datix Update Continued…………... Feedback from Young Persons Directorate Incident Pilot The DATIX Team would like to thank the YPD Directorate for their co-operation and enthusiasm in their pilot of the Incident Management Module that went live on 26th January 2009 YPD Pilot Feedback Summary The Datix Pilot phase has enabled the system to be adapted to meet the operational needs of the Directorate. Overall engagement with managers was positive, however, initial difficulties were encountered with ward staff attending training due to staffing levels / communication. Managers need to see the system in practice in order to understand the impact change required across the Directorate. The initial Datix Incident protocol was revised to meet the changing requirements of how the directorate wanted to use the system. YPD have a relatively small amount of incidents in comparison to other Trust Directorates and therefore individual learning to staff using the system can take longer to adjust. As anticipated with any new IT system the pilot encountered a number of technical glitches that have now been resolved. The Datix, ICIS and IT departments continue to work in partnership in order to support the transition from one system of recording incidents to another. During the pilot it became clear that more focussed support was required with regards to the ICIS link person role to ensure smooth transition into the correct ICIS patient record. This learning will be adapted as other Directorates commence training. In addition, the role of Superuser has proved essential to provide a means of ongoing support to managers and staff alike and is a MUST for all other Directorates. Please see below link for full feedback report for the YPD pilot. N:\Integrated Governance\Communications\Lessons Learnt Newsletter CONTACT US: Datix Team Integrated Governance Dept, Prestwich site Tel: (0161) 772 4608/ 3611 Email: Datixhelpdesk@gmw.nhs.uk PAGE 8 Lessons Learned Newsletter - February 2009 Issue 8 Complaints Received During the Last Quarter 2008 - 2009 CONTACT US: Complaints Team Integrated Governance Knowsley Building Prestwich Tel: (0161) 772 4663 Email: complaints@gmw.nhs.uk The level of formal complaints for the last quarter has been quite low. However, those received have often been complex and involved a detailed and far reaching investigation in many instances. The themes for the complaints remain constant. The highest recurring theme is staff attitude and this has run through a third of the complaints received. Whether staff believe they are acting inappropriately or not, if it is perceived as such by service users, then it is an issue and a barrier to appropriate care delivery. The next two common themes are issues around detention and discharge processes and procedures. As some services may be aware, the Complaints Regulations for the NHS changes in April 2009, and this will eventually mean greater emphasis on mediation and appropriate local resolution. The Complaints department will arrange training on these changes and any service requiring further information should contact the department on the above details. Dr. Colgan’s Casebook of Record Keeping Record keeping is an important part of providing care for service users. It provides useful information on which clinicians can base their assessments and treatment plans, not just for now, but for many years to come. It is vital, therefore, that the record is accurate but also that it contains information that is useful. For example, if a person is admitted to the acute assessment ward for what the Crisis Team thinks is a depressive disorder and there are risks of self harm, then subsequent observations and records should address this. The person’s mood should be observed throughout the day and the record should identify whether the person appeared low consistently, or whether they could brighten when distracted. Likewise, whether the person was sleeping well or eating appropriately should be observed and recorded. Be careful of offering interpretations of behaviours, for example saying that a person was ‘suicidal’ after an episode of self harm. Rather, record what you actually saw and what was and by whom as accurately as possible. It is very important that clinicians, when making treatment decisions, record their formulation or understanding of the problem in the care plan. Contingency plans should also be identified, for example what should be done in emergencies, or if the original care plan doesn’t appear to be working. It is vital that others can understand from the record how and why decisions have been made i.e. changes to medication or observation levels. Many of our service users have long standing or recurrent problems. An accurate and concise record will enable us to offer more effective treatment in a more timely fashion. Please see page overleaf for the 10 Commandments of Record Keeping on ICIS that all staff must follow. PAGE 9 Lessons Learned Newsletter - February 2009 Issue 8 PAGE 10 THE TEN COMMANDMENTS OF CLINICAL RECORD KEEPING ON ICIS (1) Make sure you meet your professional standards as regards record keeping. If you do not have any, seek advice from your supervisor. As a supervisor take your role seriously. Use the clinical records in your regular supervisory meetings. Clinical records are the property of the Trust, and are an important part of the service user’s treatment. (2) ICIS is the primary clinical record. If you do have to record elsewhere (i.e. you have a training need, lack of access to a PC etc.) ensure that there is a timely entry in ICIS identifying the whereabouts of this additional record. The Trust will have a paper-light records system by December 2009. Clinical staff have a duty to understand how to keep timely and accurate records. (3) Record all relevant information, be concise and accurate. Do not use technical language unless you have the requisite training to do so. Remember - “if it isn’t recorded, it didn’t happen”. Record what you observe, rather than your interpretation. For example, do not use the words ‘delusional’ or ‘hallucination’, but rather describe what the patient says or does. (4) Any initiation of treatment, change of treatment, or event which impacts on treatment must have an appropriate ICIS entry. Record the reasons for treatment, the treatment plan and rationale for any decisions made. When a team discusses a service user’s care, identify who will be responsible for recording the discussion on ICIS, and agree that what is written is an accurate representation of what has been said and agreed. Record who was part of the decision making team. (5) Do not use uncomplimentary, critical or judgemental language regarding the service user, colleagues or the service. …..continued overleaf PAGE 10 Lessons Learned Newsletter - February 2009 Issue 8 11 THE TEN COMMANDMENTS OF CLINICAL RECORD KEEPING ON ICIS Continued……. (6) Clearly identify 3rd party information (i.e. information from people other than the service user). (7) Clearly identify speculative thoughts/professional opinion (e.g. provisional diagnosis or psychological formulation). (8) Record progress towards meeting a care plan, not just problems encountered. (9) Understand the principles of confidentiality, and when it is appropriate to breach. If there is any doubt discuss the matter with your supervisor. (10) Make the entries useful, link them to the care plan and risk assessment. Record any changes in risk rapidly, and ensure that the risk assessment is updated regularly. For example, for a service user at risk of suicide, record items that might indicate hopelessness, despondency etc. For further Information on Record Keeping contact: Steve Colgan, Caldicott Gaurdian Trust HQ, Prestwich Tel: (0161) 772 3631 Email: steve.colgan@gmw.nhs.uk PAGE 11 Lessons Learned Newsletter - February 2009 Issue 8 PAGE 12 Medication Incidents by Sub-Category and Directorate reported across the Trust Jan - Feb 2009 ADD AFS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Bolton 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 Salford 2 1 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 1 Supra 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Trafford 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 YPD 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 Total 4 4 3 1 1 1 1 3 1 4 9 2 3 1 2 3 4 1 2 1 1 2 1 0 0 0 3 1 2 6 2 2 1 2 3 4 1 1 Administration error - wrong dose Administration error - wrong medicine Administration error - extra dose given Administration error - wrong formulation Administration error - wrong time Dispensing error - wrong dose Dispensing error - wrong medicine Lost Prescription Missing prescriptions Monitoring / follow up of medicine use Prescription admin error Prescribing error - wrong dose Prescribing error - wrong medicine Prescription altered by client Prescription not available-GP having to sign Prescribing error - Not signed by Doctor Prescribing error - wrong date Prescribing error - wrong formulation Spillage of controlled drug Totals: 33 0 4 7 2 2 2 50 We hope you have found this edition of the Newsletter informative. The next edition will be out at the end of April 2009. Lessons Learned Newsletters are co-ordinated by Louise Burton. If you have any comments about this Newsletter or any ideas for future editions please contact Louise on Tel: (0161) 772 3611 or Email: louise.burton@gmw.nhs.uk PAGE 12