Developing person-centred analysis of harm in a paediatric hospital : A quality improvement report
Lachman, Peter ; Linkson, Lynette ; Evans, Trish ; Clausen, Henning LU
and Hothi, Daljit
(2015)
In BMJ Quality and Safety
24(5).
p.337-344
- Abstract
The provision of safe care is complex and difficult to achieve. Awareness of what happens in real time is one of the ways to develop a safe system within a culture of safety. At Great Ormond Street Hospital, we developed and tested a tool specifically designed for patients and families to report harm, with the aim of raising awareness and opportunities for staff to continually improve and provide safe care. Over a 10-month period, we developed processes to report harm. We used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. We measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool... (More)
The provision of safe care is complex and difficult to achieve. Awareness of what happens in real time is one of the ways to develop a safe system within a culture of safety. At Great Ormond Street Hospital, we developed and tested a tool specifically designed for patients and families to report harm, with the aim of raising awareness and opportunities for staff to continually improve and provide safe care. Over a 10-month period, we developed processes to report harm. We used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. We measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool analysed in real time. An independent person working with the families was best placed to support reporting. Immediate feedback to families was managed by senior staff, and provided the opportunity for clarification, transparency and apologies. Feedback to staff provided learning opportunities. Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is essential to achieve safety. The high number of newly identified 'near-misses' and 'critical incidents' by families demonstrated an underestimation of potentially harmful events. This testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised situation awareness. We believe that this will lead to improved and safer care in the longer term. Place the quality of patient care, especially patient safety, above all other aims. Engage, empower, and hear patients and carers at all times. Hear the patient voice, at every level, even when that voice is a whisper. 'Don Berwick.
(Less)
- author
- Lachman, Peter
; Linkson, Lynette
; Evans, Trish
; Clausen, Henning
LU
and Hothi, Daljit
- publishing date
- 2015-05-01
- type
- Contribution to journal
- publication status
- published
- subject
- in
- BMJ Quality and Safety
- volume
- 24
- issue
- 5
- pages
- 337 - 344
- publisher
- BMJ Publishing Group
- external identifiers
-
- pmid:25825791
- scopus:84928943406
- ISSN
- 2044-5415
- DOI
- 10.1136/bmjqs-2014-003795
- language
- English
- LU publication?
- no
- additional info
- Publisher Copyright: © 2015, BMJ Publishing Group. All rights reserved.
- id
- c50e5ef1-ed1c-42ff-9f22-305ca341c54a
- date added to LUP
- 2025-08-08 18:30:48
- date last changed
- 2025-08-12 03:22:57
@article{c50e5ef1-ed1c-42ff-9f22-305ca341c54a,
abstract = {{<p>The provision of safe care is complex and difficult to achieve. Awareness of what happens in real time is one of the ways to develop a safe system within a culture of safety. At Great Ormond Street Hospital, we developed and tested a tool specifically designed for patients and families to report harm, with the aim of raising awareness and opportunities for staff to continually improve and provide safe care. Over a 10-month period, we developed processes to report harm. We used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. We measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool analysed in real time. An independent person working with the families was best placed to support reporting. Immediate feedback to families was managed by senior staff, and provided the opportunity for clarification, transparency and apologies. Feedback to staff provided learning opportunities. Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is essential to achieve safety. The high number of newly identified 'near-misses' and 'critical incidents' by families demonstrated an underestimation of potentially harmful events. This testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised situation awareness. We believe that this will lead to improved and safer care in the longer term. Place the quality of patient care, especially patient safety, above all other aims. Engage, empower, and hear patients and carers at all times. Hear the patient voice, at every level, even when that voice is a whisper. 'Don Berwick.</p>}},
author = {{Lachman, Peter and Linkson, Lynette and Evans, Trish and Clausen, Henning and Hothi, Daljit}},
issn = {{2044-5415}},
language = {{eng}},
month = {{05}},
number = {{5}},
pages = {{337--344}},
publisher = {{BMJ Publishing Group}},
series = {{BMJ Quality and Safety}},
title = {{Developing person-centred analysis of harm in a paediatric hospital : A quality improvement report}},
url = {{http://dx.doi.org/10.1136/bmjqs-2014-003795}},
doi = {{10.1136/bmjqs-2014-003795}},
volume = {{24}},
year = {{2015}},
}