The Trust is interested in finding out how colleagues at CHFT learn from incidents, claims & complaints (adverse events) and how we can use the learning to improve the way we work.

 

What do we mean by adverse events?

When we talk about learning from adverse events, we mean looking at the cause, reflecting on what happened and putting improvements in place to prevent it happening again. This could be an adverse event that happened in the area you work in, or could be by learning from something that happened elsewhere in the Trust.

 

Matron Janette Cockroft shares learning with her colleagues with a learning from experience template, which is made available to sisters on the productive drive.

 

The attached example (see bottom of story for attachment) shows how information has been shared about a patient contacting C difficile. It includes information on:

 

  • how colleagues contributed towards an adverse event
  • what should have happened
  • areas of good practice
  • what we didn’t do; and
  • information on the impact this had on the patient.

 

This approach is used on all the cardiology wards and Janette said “We talk to colleagues who have been involved in an adverse event. Though to ensure we spread the learning more widely with colleagues we use learning from experience forms, which we share via ward meetings and /or a read and sign book. The template can easily be used for any type of incident, eg a fall, a medication issue “.

 

Do you have a couple of minutes to tell us how you learn from adverse events?

Our short survey is open until 17 November - you can complete it here: https://www.surveymonkey.co.uk/r/TR7PZBY

 

The last question asks if colleagues would like to get involved in a focus group. For information the dates of the groups have been set for:

  • Friday 2nd December 2:30- 3:30pm Discussion Room 2, Learning Centre, HRI
  • Wednesday 7th December 11:15 – 12:15, Discussion Room 3, Learning  Centre, HRI
  • Thursday 15th December 9:00 – 10:00am, Syndicate Room 3, CRH

 

If you'd like to get involved please email: angela.davies@cht.nhs.uk

 

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