Interdisciplinary teamwork in pressure ulcer investigation and prevention.
Introduction:
In common with all NHS organizations in the UK, NELFT uses the Serious Incident (SI) Framework (2015) to investigate pressure ulcers. The previous process for investigating SI pressure ulcers acquired by patients under the care of the Trust caused considerable concern amongst senior nurses. These focused on loss of clinical time and lack of evidence that the report’s findings were leading to an overall reduction of harm.
The initiative aimed to increase patient safety and reduce litigation by releasing clinical time and supporting improvement work streams
Methods:
In March 2016 the Trust commenced a pilot with the aim of improving speed and consistency of learning from investigations. Each month a panel of clinical experts including investigating officers who are skilled in applying root cause and human factors analysis, TVNs, senior nurses and AHPs meet to apply a consistent investigation methodology for each case. Clinical staff are supported to attend panels and present each patient‘s case using a ‘we want to understand how this has a happened’ ethos. Contributory factors and root causes are identified and compared to identify themes in practice. Action plans to address these are developed and devolved either locally to teams, or to a pressure ulcer working group.
Results:
To date, 207 episodes of care involving the development of a pressure ulcer causing serious harm have been reviewed though the pilot.
A 45% reduction in serious incident pressure ulcers has been recorded since the panel’s inception.
Working groups have developed actions to support holistic assessment and review of vulnerable patients and projects have included a single SSKIN assessment document, a simplified pressure ulcer screening tool, a patient focused pressure ulcer alert card, a free online educational tool for carers, residential home education initiatives and annual conferences.
Feedback from staff has been overwhelmingly positive
“The whole process was made much more meaningful for staff. Everyone that attended from my team has said how much more they have learnt from attending the panel even as a one off, much more than they ever did from the years of written reports that they just felt were a chore and very much that they were blamed for the pressure ulcers”
Conclusions:
The panel model of investigation has been key to engaging staff in the safety culture of the organization and supporting innovation via the working groups. Staff involvement and representation from across professions within the organization is central to success.
References: Serious Incident Framework, NHS England, 2015