The length of reports into critical incidents could be a barrier to communicating the valuable lessons buried inside them.
Winston Churchill once said: “This report, by its very length, defends itself against the risk of being read.”
Policy makers and report writers, however, still try to write epics to cover every eventuality. The same applies to reports following inquiries into serious incidents. We pose the question: does this actually impede learning from the incident?
In medicine, we have become diligent at reporting incidents and there is much research on incident and near-miss analysis. Beyond healthcare, many “high reliability organisations”, for example, in the aviation and nuclear power industries have robust reporting systems from which those organisations aim to learn.
However, the stage that seems to get the least attention – although, arguably, the most important - is that of communicating the lessons learned so that the same mistakes do not re-occur.
Sadly, recent press coverage reveals that many homicide enquiries highlight the same errors or oversights repeatedly.
Lost in translation
What do we know about how we deliver information in our large and complex organisations? Most trusts now use intranets by which staff access policies and reports, and they send emails - which are potentially fast, efficient and leave an electronic trail. However, how many staff actually have ready access to their email when taking into account the number of computers in wards and offices, shift working and competition for use of computers for other essentials such as Rio? We know, too, that incident review reports do not always filter down as intended.
After an incident, there is usually a debriefing meeting, but this will only be attended by a limited number of staff. Nurse managers may subsequently hold meetings and training sessions, but again, these are not a catch-all. Current processes for making all frontline staff aware, reasonably rapidly, of inquiry recommendations are not effective, limiting the extent of positive change in practice.
At Broadmoor Hospital, part of West London Mental Health trust, we have examined what happens to information from the incident inquiry process and how to ensure that recommendations and learning points reach frontline staff. This followed an increasing emphasis in the trust by the incident management and review group at Broadmoor Hospital on effective learning from serious incidents.
Our own incident reporting and review policy classifies incidents as one of three types depending on the level of severity, each with its own process and defined timelines for completion.
We wanted to look at alternate methods of information dissemination which embody the principles of being high impact, easy to read and memorable. A4-size poster summaries were prepared for four recent inquiries following incidents at Broadmoor Hospital. These summaries charted the findings under the headings: What happened? What did the investigation find? What can we learn from the incident?.
Did it work?
We designed an audit to examine whether displaying these summaries in staff areas led to improvement in nursing staff’s knowledge of learning from serious incidents.
First, we assessed staff knowledge before the summaries were displayed. We used a questionnaire to interview 40 staff on the four wards in which the incidents had occurred. We found that despite a reasonable knowledge of the general incident policy, few staff were aware of these specific incidents or the resulting changes in policy and practice. The post-incident reports were long and held on the intranet; but generally staff did not access them, let alone read them.
To remedy the issues from this initial audit, we displayed the incident summaries in the ward offices and in staff rest areas in the format described above.
Staff were then re-interviewed after five weeks. The findings were positive. There was a dramatic improvement in staff knowledge. All were now aware of the incident review and reporting policy. Most were aware of the incident categories and review levels. Almost all knew and were reasonably knowledgeable about the particular incidents that had occurred. Three-quarters had seen the incident review, were aware of the recommendations and what practices had changed. Above all, most preferred to read a simplified version of the incident review.
The essence of reporting
We concluded that the best way to get this vital information to staff on the ground is to ‘distil the essence’ and make it easily accessible. As a result, all of our incident review reports are now summarised in A4 posters which are well advertised across Broadmoor Hospital.
How do we “distil”? It is important to ask ourselves, for any piece of information: What does our audience really need to know? What can they find out for themselves, and where? What do we want them to do as a result of reading it? Usually less is more - and more easily remembered - but of course we need to avoid losing crucial meaning in “dumbing-down”. Hardest for clinicians under pressure, we need to resist the temptation to “tell them everything”.
The Audit was designed and completed by Dr Kaysi Thinn, specialist registrar; Dr Amalsha Vithaanarachi and Dr Pallavi Bujarbaruah, both core trainees, under the supervision of Dr Mrigendra Das, clinical lead and consultant in forensic psychiatry at Broadmoor Hospital, West London Mental Health trust.
The authors thank all the staff who participated in this audit and Lucy McGee, director of communications in the trust.
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Dr Kaysi Thinn is an honorary specialist registrar in forensic psychiatry at Broadmoor Hospital.