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GP example: Learning lessons when things go wrong and making improvements
Key question: safe?
S2: Are lessons learned and improvements made when things go wrong?
An open safety culture
A rural practice serving approximately 29,000 patients.
This practice had a comprehensive system in place to keep patients safe from harm. The level and quality of incident reporting ensured a robust picture of safety. Significant events meetings were held bi-monthly and included the significant event lead, quality assurance officer and a member of staff from each team. This ensured that improvements and feedback were fed back to the whole practice.
There was evidence from meeting minutes that the practice had learned from significant events and that the findings were shared with relevant staff.
This practice was rated outstanding because they demonstrated an open culture in which all safety concerns raised by staff and people who use services are valued as integral to learning and improvement.
Learning from significant events
An urban practice with 7,700 registered patients.
The practice had a system in place for reporting, recording and monitoring significant events, incidents and accidents. The practice recorded the events in categories which enabled them to look at trends, for example, medication, clinical assessment and consent, communication, and confidentiality. Significant events were reviewed on a regular basis and records showed that the practice learnt from external safety incidents to help improve the patient experience. The practice proactively sought feedback and had invited a representative from the commissioning support unit to their next significant event meeting to discuss how they could improve the feedback they received following events relating to secondary care.
Staff, including receptionists, administrators and nursing staff knew how to raise an issue for consideration and they felt encouraged to do so.
This is outstanding because the practice showed its dedication to learning from significant events and their willingness to share this learning outside of the practice.
Sharing safety lessons with the multidisciplinary team
A suburban practice with 3,800 registered patients
This practice has a strong multidisciplinary approach to learning. It demonstrated how it shares learning from significant events with other providers and multi-professional agencies in the area, so that lessons could be learned and systems changed to improve care for patients.
For example, a recent significant event was recorded and raised with the local hospital laboratory to ensure that the relevant professionals were aware of the details.
Significant events were discussed at multi-disciplinary practice meetings, which were attended by clinicians from other disciplines such as Macmillan nurses, safeguarding leads, community midwives or health visitors. The minutes from these meetings showed reflective practice and that information was shared to reduce risk and improve services for the future.
- Last updated:
- 10 August 2017