Proud to be working with the National Health Service (NHS) in Scotland
The NHS is an environment where safety is of the utmost importance to employees and patients 24 hours a day, 365 days every year. The Keil Centre recently worked with the NHS to provide training on Procedures and Incident Investigation.
NHS Lothian has been making great improvements to reduce the risk of human error in their laboratories. The trust provides round-the-clock clinical and medical laboratory services and a comprehensive range of investigations for the Lothian region. Making an error in performing laboratory procedures can have a direct impact on patient and public safety, from failing to diagnose an illness to exposing a biological hazard.
The Keil Centre is working with NHS Lothian to provide a training programme for developing effective procedures. Our course outlines the link between procedures, human failure and patient safety, the process for developing them, and the key principles for the presentation of written instructions. NHS Lothian have now re-written procedures that only a brain surgeon could once understand to one that most teenagers could now follow.
Feedback comments from the course included "A fantastic course and I cannot believe we haven't included human factors as much (before) in our Standard Operating Procedures. It is really good to understand the layout/ ease of reading (principles). It will be extremely useful in my current role."
Nadine Wilkinson, Compliance [Quality] Manager, Department of Laboratory Medicine commented: "Gaining an understanding of the discipline of Human Factors has been a steep learning curve for Lothian laboratory medicine, but one that we can definitely see the benefits of. The courses delivered by the Keil Centre have been specifically designed and focused to break down what can be a complex process into understandable and bite sized chunks that we are starting to embedded into all of our procedures and processed to ensure that we deliver a patient focused, safe and effective service."
According to NHS Improvement, incidents in the NHS “can have lasting social and physiological impact for patients, families, carers and staff alike. This has fueled recent efforts to improve investigation practice to better support those affected by incidents and to prevent repetition of harm.”
Determining why incidents have happened is immensely important to ensure that lessons are learned, and the underlying causes addressed, to reduce the potential for future incidents.
In healthcare, there has always been a vivid realization that even the most highly trained and competent professionals can make mistakes under the wrong conditions. Critical activities that could impact on the safety of patients and staff are checked and double-checked meticulously. Sometimes, however, as in all walks of life, someone makes an error or a conscious decision to step beyond the procedures in the interests of getting the job done. Sometimes these human failures are spotted, but sometimes they are not, and they lead to an incident.
NHS Ayrshire and Arran wanted to understand more about the underlying causes of such human failures. They wanted to treat “human error” or “intentional non-compliance” as a key focus point for their reviews, rather than the end point. They asked The Keil Centre to deliver their Human Factors Analysis Tools (HFAT®) training to some of their lead reviewers over a two-day training course in Ayr. Delegates were trained in the analysis of human failures to determine their root causes and also received training on using interviewing skills to uncover some of the reasons why people behaved the way that they did. Delegates reported that the course provided “first class delivery, materials and learning” and that they would be “integrating these newfound tools and techniques into our adverse events review process”.
Hugh Currie, Assistant Director for Occupational Health, Safety and Risk Management said of the training course: “This was an excellent, very well delivered course that added an extra dimension to our review skills. Delegates will be able to put their new knowledge to good use whilst playing a part in organisational significant adverse event reviews.”
For more information on incident investigation, please contact Richard Scaife (firstname.lastname@example.org)
For more information on procedures, please contact Janette Edmonds (email@example.com)
References: The Future of Patient Safety Investigation. NHS Improvement publication C 11/18, March 2018