Patient safety: making the most of an incident

Reporting of patient safety incidents in Cambridge City and South Cambridgeshire primary care trusts has been relatively low.

An incident learning group, formed in 2004, brings together clinicians and managers to review incident reports, formal complaints and patient advice and liaison services data. Discussion enables common themes and areas of risk and learning to be identified.

Themes and recommendations are reported quarterly to the PCTs' clinical governance committee and boards and evidence provided for compliance with Healthcare Commission standards.

As a result, PCT staff report incidents and encourage patients to contact PALS or say where they feel services can be improved. There was a 10 per cent increase in incident-reporting in 2004-05 and a further 8 per cent during 2005-06.

The PCTs' incident reporting process has been extended to primary care, including the GP out-of-hours emergency service. Around 35 per cent of GP practices use it.

Themes identified by the group led to the following improvements:

PCT input to the trained nurse induction at our acute trust to raise awareness of community services and improve communication over discharge planning.

Awareness-raising with healthcare staff on dealing with an expected death outside 'normal hours'. Processes for staff evidencing competencies in child protection.

A joint 'social footcare service' for older people has been implemented with East Cambridgeshire and Fenland PCT, St John Ambulance and the local homeless project.

Audits of medicine management to improve processes.

Sharing of clinical information between general practice and the GP out-of-hours service has improved.

Staff training has included manual handling, customer services, learning from incidents, conflict resolution and root cause analysis.