Sign Up to Safety





The Five Sign Up to Safety Pledges


  1. Put safety first.  Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally


Practice’s response:


  1. Increase incident reporting and learning from incidents in primary care both clinical, including medication incidents and non-clinical


  1. Support learning from service user feedback including the Friends and Family Test



Progress made:


  1. We have always encouraged staff to report incidents that they feel should be reviewed by the Practice (both good and not so good).  In 2014/15 we had a total of 36 reported SEAs (Significant Event Audits).  From 1/4/15 until 22/12/15, we had a total of 20 reported SEAs.  The threshold for reporting has not changed, so we hope that it is a good sign to have fewer incidents to report so far this year


  1. We are reviewing the feedback from service users including the Friends and Family Test comments and the NHS Choices reviews, although it is not easy to put these in context as to what the patient was experiencing at the time it was written.  SEAs and feedback are discussed at monthly GP/staff training meetings as a learning opportunity



  1. Continually learn.  Make their organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and  monitoring how safe their services are


Practice’s response:


  1. We will:
    1. Review our current incident reporting process to assess and try to improve:

                                          i.    How decisions are currently made about what is an incident to be reported

                                        ii.    How they are reported

                                       iii.    How they are discussed

                                       iv.    How learning is shared, both within the Practice and with the patient

                                        v.    Whether action points from similar incidents have been implemented

  1. We will publish feedback in the form of “you said, we did” outcomes on our website and on the TV screens within the Practice



Progress made:


  1. We have continued to have a low threshold for incident reporting.  We have a new Salaried GP who joined us fairly recently and she has some ideas from her previous Practice.  We will be discussing these in early 2016 to see if we can learn anything about the way learning is shared and discussed, both within the Practice and outside, and whether this can be improved


  1. We endeavour to ensure action points are implemented as in the example of an SEA regarding a patient who arrived at the Branch Surgery with chest pains at a time that only 2 receptionists and 2 GPs on duty.  The patient was treated at the Surgery, taken to hospital by ambulance and subsequently recovered.  The situation was discussed with all those involved and, as a result, some actions have been taken to improve the process, as follows:-


  1. Notices have now been provided at reception at both the Main and Branch sites informing patients who may attend that an emergency is in progress and to take a seat until a receptionist is available.  This is for use when limited staff numbers are available to help the GP with obtaining emergency trolley, telephoning for an ambulance, etc.


  1. All GPs and Nurses have been reminded of the code to access the CD cupboard at each site – no staff member has the code for security purposes


  1. Review of emergency trolley equipment.  Agreed to improve labelling on the trolley


  1. A form that is used to record urgent details when a patient attends in an emergency has been updated and improved to aid the GP who is seeing the patient.  This is kept with the emergency notice for immediate access


  1. Once the Defib paddles have been used, these cannot be reused.  An agreement has been reached with the other users at Berrow Health Campus (Parkfield Dental and Mulberry Centre) that should this be the case, we would all be willing to share a Defib whilst replacement paddles are ordered (usually 24 hours to replace the paddles)


  1. Everyone involved in the incident was congratulated for their prompt action


  1. We are in the process of pulling together a “You Said, We Did ….” information on outcomes for our TV screens and website and this will be available in early January 2016.



  1. Honesty.  Be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong


Practice’s response:


  1. Incident reporting, where patients are affected:
    1. Under the “Duty of Candour” we will always discuss openly and honestly with patients and their families any incidents that may affect them
    2. Discuss the outcomes of any investigation
    3. Inform them of any changes that have been made to prevent a similar incident occurring in the future



Progress made:


  1. When patients or their families raise concerns, or a concern is identified by a member of staff, we will always discuss the issues openly and honestly with the affected patients or their families (subject to the necessary patient consent).  This is a usual part of our Complaints process and, even if it is not a formal complaint, but the patient is concerned, they will receive a full response


  1. Patients are advised if we are investigating the concern and will be informed of the outcome.  They will also be offered the option of a face to face discussion with a GP or Manager (depending on the nature of the concern), if they wish to do so


  1. As part of the closure of the concern, we will also inform patients of what changes, if any, have been made to prevent a similar incident in the future


  1. Our Practice Manager has recently attended some update training on the Complaints/Concerns procedure and how to improve this and we will be working on any potential improvements to the system asap



  1. Collaborate.  Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use


Practice’s response:


  1. Review our current incident reporting process to assess and try to improve:
    1. How learning is shared, both within the Practice and with the patient
    2. Whether action points from similar incidents have been implemented
    3. Sharing learning with other local services that may be affected either directly by the incident or who may be able to share learning with other Practices or Providers eg CCG, Hospitals



Progress made:


  1. We review all incidents within the Practice as they occur and as a group at least annually and will be including in our next annual review an assessment as to whether there has been a previous incident of a similar type and what action was taken as a result


  1. We share learning via SEAs and the Datix system with Somerset CCG, who may well involve other Practices or Providers in the learning.  If we have an incident that involves an outside agency eg local Hospital, then we will always share the SEA directly with the Hospital concerned as well as the CCG



  1. Support.  Help people understand why things go wrong and how to put them right.  Give staff the time and support to improve and celebrate the progress


Practice’s response:


  1. Continue to discuss within the Practice if things go wrong and what could be done to put them right, with sufficient support and training for staff if necessary.
  2. Review any progress made and ensure people are aware of improvements in a positive way



Progress made:


  1. We continue to review incidents and to support staff with necessary training where appropriate.  This may be as a one-to-one, or shared learning with all staff members if it is something that would be helpful to everyone


  1. In November we held an Away Day for all Practice staff that has generated a host of ideas to improve services for our patients to help the staff to help them.  We are gradually working our way through these ideas to implement the ones that were agreed by everyone as being most beneficial.  The first achievement was to provide text message appointment reminders to reduce the number of patients that fail to attend their appointments – on the first day we received an email cancelling an appointment for a review for a patient who had been away on holiday and did not know she had the appointment until the text message arrived.  The appointment was cancelled allowing someone else to take it


  1. We have a regular “Employee of the Month” to celebrate those staff members who have gone above and beyond the call of duty to help our patients or their colleagues


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