Patient Safety at Derbyshire Community Health Services
Patient Safety is the freedom from harm in healthcare and is a process by which an organisation makes patient care safer.
This involves learning from all care that we provide whether that goes as expected, exceeds expectations or does not meet expectation.
A Patient Safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare.
Patient safety incidents include:
- Adverse events
- Mistakes
- Clinical error
A near miss is any incident that could have led to harm, but didn’t, either by chance or through timely intervention.
All patient safety incidents should be reported via Datix within 24 hours, the incident manager must complete an initial review within 48 hours to establish any immediate support and safety actions. This review should include verifying the accuracy of the incident description, amending harm levels, and ensuring accurate coding. The incident manager than has 14 days from the reported date to carry out a full managers investigation. Once the investigation is complete, the outcome and actions should be documented in the managers investigation section within Datix.
For further detail around incident reporting please see the Incident Reporting Policy.
Once the incident has been reviewed by the manager it will be sent for processing by the Patient Safety Team who will ensure the report meets national guidelines, and where appropriate are fully reviewed and further learning responses identified. The majority of the patient incidents are automatically sent to NHS England via the LFPSE (Learn from Patient Safety Events) portal.
Please click here for additionally national information regarding LFPSE.
Click here to view categorisation of Harm when reporting Patient Safety Incidents
For further information please visit the Datix page.
To support the NHS Patient Safety Strategy which sets out the national focus on how to further improve patient safety, NHS organisations are to work under the new Patient Safety Incident Response Framework (PSIRF). This framework outlines how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.
DCHS is working under this framework and the current DCHS Patient Safety Incident Response Plan is available here.
The Patient Safety team run a number of training courses, for more information on any of the below please contact the Datix helpline.
- DatixWeb Incident and Risk Form Completion (1:1 or group sessions)
- DatixWeb Incident and Risk Managers Review (1:1 or group sessions)
- Risk Management (virtual group sessions)
- Patient Safety and Risk Management is introduced on the monthly corporate induction
- Investigation training (virtual group sessions) (including Patient Safety Strategy, Patient Safety Incident Response Framework and Plan, Duty of Candour, human factors, and investigation tools.
An After Action Review (AAR) is a learning response method that supports organisations to respond to a safety event or other event for the purpose of learning and improvement.
Within DCHS, it is every staff member's responsibility to escalate concerns that could potentially be a risk to the organisation. This is known as horizon scanning. When a potential risk is identified it is to be recorded on Datix and submitted for further review prior to approval & capture on the Corporate Risk Register. Once approved, a nominated service representative will take the lead as risk reviewer and ensure the risk is actively managed and updated.
For further information refer to the Risk Management Policy.
Report a Corporate Risk here.
Anti-Ligature Management
Each clinical area that has been identified as requiring a ligature risk assessment has an Anti-Ligature Lead who completes a review of the risk assessment on an annual basis.
Reminders of review dates are provided by the Patient Safety Team and all risk assessments are collated by this team to enable an annual report to be provided to the Clinical Safety Group. Queries regarding the risk assessment tool should be directed to the Patient Safety Team. Any queries regarding advice on ligatures should be directed to the appropriate Operational Service Line Managers
For further information see Ligature Management Policy
DCHS strives to ensure that any learning from deaths is shared across the Trust to provide information, quality improvements and celebrate excellent practice. This is completed through the review of any deaths where learning or concerns have been identified. There is a structured process to ensure joined up working across the Trust and dissemination of information.
The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care.
Alerts available on the CAS website include National Patient Safety Alerts (from MHRA, NHS England and NHS Improvement and the UK Health Security Agency (UKHSA)), NHS England and NHS Improvement Estates Alerts, Chief Medical Officer (CMO) Alerts, and Department of Health & Social Care Supply Disruption alerts.
National Patient Safety Alerts relate to a wide variety of subject matters. All NHS Trusts are monitored on these types of alerts with the CAS website providing monthly details on all NHS organisations response rate. As a result, the Trust is obligated to distribute these alerts to a wide range of their services/department leads to check if they are applicable, or to provide the information they contain. These PSA Alerts have a deadline for acknowledgement of receipt, and a further deadline by which we are required to respond.
For more information please contact The Patient Safety Team or visit the CAS website.
Safe care works to ensure that clinical literature developed within DCHS is safe, effective, and efficient. This is achieved through robust processes that support regular, comprehensive and informed reviews of all clinical policies, procedures, guidelines, documents and patient information leaflets. This system ensures that all DCHS clinical literature is evidence based, up to date and meets the needs of clients, patients, carers and staff with the principles of accessibility and equality applied.
Being open/candour is a process NOT an event, it should be on going and is about being open about all aspects of the care a patient has received, including when things go wrong.
The Being Open principles (See policy) and ethical Duty of Openness applies to all incidents and any failure in care or treatment. The Duty of Candour applies to notifiable safety incidents.
A notifiable safety incident must meet all 3 of the following criteria:
- It must have been unintended or unexpected.
- It must have occurred during the provision of care.
- In the reasonable opinion of a healthcare professional, it already has, or might, result in death, severe or moderate harm to the person receiving care
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Significant (Moderate Harm or Injury) |
Incident that resulted in a moderate increase in treatment, possible surgical intervention, cancelling of treatment, or transfer to another area, and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care. |
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Major (Severe Harm) |
Incident that appears to have resulted in permanent harm to one or more persons. For example: a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions, including removal of the wrong limb or organ or brain damage, that is related directly to the incident and not related to the natural course of the service user's illness or underlying condition |
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Death |
Incident that directly resulted in the death of one or more persons |
When a notifiable incident is identified the following must occur:
- Tell the relevant person (defined below), face-to-face, that a notifiable safety incident has taken place
- Apologise
- Provide a true account of what happened, which covers what is currently known of what has occurred
- Explain to the relevant person what further enquiries or reviews are expected to occur
- Follow-up by providing all the above information, including the apology, in writing, and provide an update on any enquiries
- Keep a secure written record of all meetings and communications with the relevant person in accordance with Information Governance requirements.
- Support all those involved to cope with the physical and psychological consequences of what happened.
Please refer to the Duty of Candour Policy for further details.
DCHS Shout Outs will no longer exist under the Shout Out Title. The Patient Safety Team will continue to recognise and reward staff and Teams when they have implemented or developed a process that has had a positive impact on Patient Safety, this will be extracted from the IRIS and ROSE submissions.
ALL STAFF RECONGNITION SHOULD BE SUBMITTED BY USING THE IRIS OR ROSE FORMS.
IRIS AWARD - Do you know a colleague who goes above and beyond? The IRIS award, celebrates the amazing staff of Derbyshire Community Health Services. Recognise a colleague or team for their outstanding dedication to patient care and service excellence. To nominate a staff member or team click here.
ROSE AWARD – For members of the public to complete. Do you know a DCHS staff member who has made a real difference, or delivered extraordinary care? Then now is the chance to give them the thanks and credit they deserve, with our new Recognition of Staff Excellence (ROSE) award. To nominate a staff member or team click here.
Patient Safety Team Central Support Line
T: 01246 515807
Graham Kinsey - Patient Safety Specialist (Lead in Patient Safety & Risk Management)
T: 01246 944198 E: graham.kinsey@nhs.net
Scott Goodwin - Patient Safety Manager
T: 01246 944183 E: scott.goodwin2@nhs.net
Lisa Weatherall - Patient Safety Advisor
T: 01246 944181 E: lisaweatherall@nhs.net
Trevor Hall - Patient Safety Officer (Patient Incidents & CAS)
T: 07557 177203 E: trevorhall@nhs.net
Laura McLeavy - Patient Safety Officer (Mortality Review & Risk)
T: 01246 944178 M: 07385 112138 E: laura.mcleavy1@nhs.net
Rick Aspinall - Risk Manager
T: 07584 003861 E: rick.aspinall2@nhs.net
Hannah Thompson - Mortality Review Facilitator
T: 01246 944973 M: 07774 556818 E: hannahthompson@nhs.net
Sarah Martin - Clinical Lead for Safe Care
T: 01246 944399 E: smartin17@nhs.net
Val Riley - Safe Care Officer
T: 01246 944237 E: val.riley@nhs.net