PEPs - Clinical Quality and Evidence

Module 1 - Clinical Quality

Tools for safety

Image by NASA Goddard Space Flight Center on Flickr

We have mentioned the SBAR system (Setting Background, Assessment, Recommendation / Readback). Hopefully within your placements you will be seeing some good examples of clear team communication.  

The link following link takes you to an explanation of how the system works and some example film clips:

We suggest you start with Acute Escalation.  If you watch a couple of scenarios you will understand the increased potentials for error that exist with unclear communication, in contrast to using the structure of SBAR for improved safety.  For a more gentle introduction to the topic there is also an optional 20 minute film involving Phil Hammond called the ‘Trouble with Handovers’)  Finally refer back to the 3x3 grid: Where does the SBAR system fit in?  Start using this system whenever you have an opportunity – You will be able to practice this further in Year 5 communication teaching.

SBAR can be seen as an example of a simple System control  – as used in all Industries for efficiency and safety.  You might say it depends on two processes – both the giver and receiver following protocols, but aided by their organisation – eg by providing training, resources – like message pads and review / audit.  There are many examples of these in health care, usually relying on staff following processes or ‘rules’ to prevent or minimise harms.  The problem is that we all tend to break rules through three behaviour patterns, either ‘routinely’ – e.g. bad habits, or quite often because of good ‘reasons’ – logical exceptions or short cuts that may seem a good idea at the time. More rarely we violate rules through ‘recklessness’!  

To complete this section let’s look at a procedure for learning after adverse events or ‘near misses’ have occurred.  The Significant Event Analysis BMJ module introduces you to reporting systems for such ‘incidents’ and gaining an understanding of contributory factors (Root Cause Analysis). It also discusses accountability and mentions our fear of ‘blame’ (see also the MMS blog on the Francis report).

The BMJ module is hospital focused, but we know that GPs are just as sensitive to discussing error: for instance when harms occur they may be reluctant to involve patients in the learning process and prefer to use national reporting systems.  

One good example of the latter is the RCGP system enabling remote peer review for GP SEAs in Cancer management. Follow the link below and then view the sections titled 'Significant Event Audit: Cancer Peer Review Pilot (1 July 2012 - 30 June 2013)' and 'Annotated SEAs' which are half way down the page:

For other ideas on Quality improvement in Cancer and tips important for your clinical learning, see the following link. Also view the 'Top Tips' section on the right of the page and look at the item titled 'Think triggers for early referral in suspected cancer'.

In summary, while we hope your teachers will be good role models, unfortunately you will not always see an ‘open culture’.  You need to take the trouble to make sensitive enquiries within a team you have got to know – not easy in a short clinical attachment!  You could ask your supervisor how their team or practice reviews deaths or recent cancer diagnosis.  So if approached in the right way, many doctors will discuss patient harms and you could learn much from this, or with appropriate briefing from attending or better still participating in a team review meeting in either primary care or hospital.

How to report and audit Significant Events; a users’ guide (1 hour)

Please visit The University of Manchester Library for instructions on how to access BMJ modules both on-campus and off-campus.

After completing this learning package you should:

  • Know the procedures for reporting and following up adverse incidents
  • Understand why we should report adverse incidents
  • Understand the basic concepts of root cause analysis.