Learning from Excellence

Adrian Plunkett, Birmingham UKSMACCJune 16th 2016@adrianplunkett

Source: Eurocontrol. From Safety 1 to Safety 2. A white paperwww.eurocontrol.int

Trying to understand safety by only looking at incidents is like trying to understand sharks by only looking at shark attacks

Attributed to Bob Wears

Theirs nothing worse than misplaced apostrophe’s

1 + 1 = 22 + 2 = 43 + 3 = 74 + 4 = 8

5 + 5 = 10

Rieger at en.wikipedia derivative work: JohnKiat (talk) derivative work: JohnKiat [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or GFDL], via Wikimedia Commons

Negativity culture:

Adverse eventsErrorRisk

IR1 / DatixSIRI / SUI

Never event

Second victim effectThird victim?Fourth victim?

Source: Eurocontrol. From Safety 1 to Safety 2. A white paperwww.eurocontrol.int

What do people report?

No one has reported themselvesReports focus on what was DONE

Often ‘motivational > informational’Many themes

… took her own initiative to design a bespoke care plan on ventilation

weaning on a patient with complex needs that is clear for both her

colleagues and parents to understand. This meant that everyone involved in this

patient's care had a shared mental model

“Great innovation and organisation of the ward-round with a new structure trialled

that was more efficient and more enjoyable for the team”

“...during a busy shift ... took the time to communicate with family ... compassion and

kindness... the family was comforted and reassured... Empathy, kindness, extremely

supportive towards the whole family.”

“...was looking after a patient on PICU. During the morning ward round not only had he spotted a ten fold drug dose error

which he flagged for our attention, he also challenged very appropriately and

constructively about why a child with a viral infection was on antibiotics.”

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov-

14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov-

15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Apr-

16

May

-16

0

10

20

30

40

50

60

70

80

90

100

Frequency of IR2 reports

Outside PICUPICU

PRIP study

Pre Post0%

20%

40%

60%

80%

100%

Effect of positive reporting on prescribing practice

Gold standardNot gold standard

Study period

Perc

enta

ge o

f pre

scrip

tions

Imagine you had three wishes...

“... The two most powerful words in the English language are ‘well done’”

Sir Alex Ferguson

“Saying ‘thank you’ or ‘well done’ might be the simplest quality improvement intervention of all”

Dr Emma Plunkett