Last weeks training day ... what did we do?

On Wednesday the practice closed in the afternoon for staff training and development. We spent the time looking at Significant Events. We define Significant Events as where something did or may have led to some significant harm happening to a patient (usually) or member of staff.

The whole practice was involved; doctors, nurses and administration staff. We split into small groups and worked through a proforma looking at the event and then produced an action plan. The Significant Event proforma looks at what happened, what issues did it raise, what was done well, what was not done well, what could be done differently in the future and what learning needs did it identify. The action plan each group was charged with producing looked at what we need to do differently, who is going to be responsible for implementing this change, when are we going to start and how are we going to measure any changes.

We looked at five significant events; patients being sent letters about pathology results unnecessarily, two patients with cancer whose urgent fast track referrals had been blocked, patients with a new diagnosis of depression who are not followed up, a problem caused to patients having blister packs whose medication was not changed in a timely manner and lastly an issue with a patient with insulin controlled diabetes who had not attend either hospital or practice clinics.

The outcomes following our action planning varied from; writing a letter to Mid Yorks Hospital Trust chief executive about the blocked fast track referrals, developing a new safety net procedure for patients who are newly diagnosed with depression, planning an education and calibration session for doctors on how we interpret and act on borderline results.

We plan to review progress in the areas raised by these significant events - so watch this space for more news!