Q5: Do we get the right information? (Has care been safe in the past, is it safe today and will it be safe in the future?)
Why is it important?
Learning from all sources of data together provides an organisation with a true reflection of where things are going wrong and what is needed to prevent minor events from becoming more major and serious adverse events. A resilient system is one that expects the unexpected. It anticipates mistakes and risks, and creates barriers so that their effect is either lessened or even prevented.
What does 'good' look like?
- We have an integrated approach to governance and draw from all sources including:
- reported adverse event themes;
- significant adverse event reviews;
- clinical risks;
- Scottish Patient Safety Programme datasets;
- patient experience;
- staff experience;
- prescribing data;
- unexpected deaths;
- Hospital Standardised Mortality Ratios; and
- triggers highlighted from case note reviews.
- Our NHS Board scrutinises these data effectively to assure ourselves that our organisation learns from them, takes action and monitors the impact.
- An infrastructure exists to support data collection and reporting, and systems are in place to effectively and efficiently capture, assure, analyse and report data.
- We use patient and staff stories to put a 'human face' on the numbers and actively seek accounts of patient and staff experience wherever possible.
- Our NHS Board is kept informed of serious and ongoing issues and recognises the links between staffing, quality outcomes and patient safety.
- We maintain a state of intelligent wariness even in the absence of poor outcomes.
- We have an atmosphere of constant vigilance to avoid the pitfall of 'it could not happen here'.
Email: Sarah Hildersley