Could it happen here?
Safe and effective message
taking and recording
Could it happen here campaign
Why put patient safety first?
Why learn from others?
Quality is:
Patient safety, patient experience and clinical outcomes.
The public expect the NHS to learn, improve and share
good practice.
Care should include – assessment, prevention,
treatment, education and communication delivered with
compassion and empathy.
Could it happen here campaign
What happened?
Following a child death in Hampshire, a Serious Case
Review was undertaken. During the investigation it was
found that staff in a Child Health Team did not have a
robust process for the taking and recording of messages
from clients.
Contact between parents of the child and the Child Health
Team was not recorded in RIO.
The outcome of this meant there was missing vital
evidence which could have been used in the subsequent
court case.
Could it happen here campaign
What worked well?
Clinical Record Steering Group met to develop message
taking process for both adult and child clients
All members of child health team were represented including
admin in the development and implementation of the new
process
An emphasis was on safe clinical record keeping with a
transparent process in place that all clinicians and admin
could undertake
Could it happen here campaign
What did we learn?-across all teams, across all Divisions….
Teams require a clear and transparent process of taking messages
that can be recorded, actioned and audited
RIO is used by other health services and should be the single point
of entry for information held on children and adults in order to
assess and provide effective care planning
We can provide a more responsive service to children and adults as
vital information is stored securely enabling it to be shared if
necessary to support the safeguarding of our patients and service
users
Could it happen here campaign
What are we doing differently?
A process was developed with a team approach to include
admin. A formal message template was produced with clear
guidelines on completing and actioning.
This ensures clinical record keeping is adhered to by all team
members and keeps the child safe by accurate and timely
clinical entries
Open and honest team approach to learning and sharing
Clarity around the importance of recording all contacts with
clients as evidence of our planning their care
Could it happen here campaign
Discussion – 10mins
Could it happen here?
What was the effect to patient safety, patient experience
and clinical outcome?
Is it acceptable to your professional and organisation
values?
Could it happen here campaign
How do we prevent the incident happening again?
How do we introduce good practice?
How do we embed and audit good practice?
Discussion 10mins
Could it happen here campaign
What have you learnt from this incident?
What will you do differently to improve patient safety,
patient experience and clinical outcome?
What 3 things will you do today to ensure
it doesn’t happen here?