29 TIPS, TRIPS & TRICKS – nationwide establishment of departmental bulletins sharing learning from mistakes and masterpieces

Introduction Mistakes, near-misses, and masterpiece moments happen. Every time, a learning opportunity arises for the individuals involved and the wider medical community. Sharing learning not only to promote a positive culture, but also to lessen the likelihood of incidents being repeated by another unsuspecting healthcare professional. Although the actions of seniors set a precedence for juniors to follow, organisational factors undoubtedly play a huge role in encouraging or discouraging shared learning. The aviation industry has recognised this and employ a system of voluntarily submitted incident reports, immunising reporters from blame, with dissemination of the learning points to the whole aviation community to lessen the likelihood of repeat events. This is known as the Aviation Voluntary Safety Reporting System (ASRS). This intervention is incredibly translatable to the NHS and is vital not only for optimising patient safety, but also staff psychological safety. Aims and objectives of the research project or activity Inspired by the aviation industry, the aim of this project was to implement a similar no-blame learning bulletin programme into local departments It was hoped that by piloting in a single specialty at a single trust and demonstrating successful implementation at multiple sites, a translatable toolkit could be devised for departments to implement nationwide in multiple specialties and incorporate into their clinical governance framework independently. Ultimately the project was devised to foster a culture of constructive and psychologically safe learning in departments throughout the NHS. Method or approach A baseline survey was distributed to a pilot orthopaedic department at a single site investigating satisfaction with current feedback methods and opinions regarding introduction of a bulletin. A dedicated email address was created for staff to submit cases and submission period advertised via email and posters in high-use areas. A pilot bulletin was designed based on anonymised submissions and emailed out departmentally. A feedback survey preceded further local editions and implementation at a secondary site. Feedback drove further developments and sustainability. Independence of further site set-up was then designed. An online toolkit was created containing templates alongside a 'How-To' and bulletin archive. Registration of site involvement was stipulated for toolkit access. Nominated consultant leads and rotationally nominated trainee editors in each department was recommended. Programme details were added to the national association website with a contact provided for registration and toolkit access. Completed bulletins are added to the archive. Findings Amongst 19 baseline survey respondents, face-to-face conversations were the most positive experience and Datix the most negative. 26% admitted taking no action when mistakes occurred. Barriers included lack of time or confidence, concerns regarding bullying accusations and diminishing morale, and uncertainty as to the appropriate recipient. registrars were unable to attend morbidity and mortality (M&M) meetings. 100% felt a bulletin would be educational and change practice, 95% felt it would encourage feedback and improve patient care and safety. 63% felt it would reduce blame culture. During the pilot, 6 submissions were received over 3 weeks. Positive qualitative feedback was received following the pilot edition, a consultant lead was nominated and rotational trainee editors established. The secondary site experienced similar positive engagement and feedback. Regular bulletins are now established within these departments (5 at the pilot site in 18 months, 3 at the secondary site in 12 months) composing learning points from staff submissions alongside M&M cases and Datix reports. Bulletins are emailed and placed in coffee rooms and theatre. Following national website promotion and toolkit creation, five further orthopaedic sites nationwide have registered onto the programme and accessed the toolkit within 2 months. Initial bulletins are awaited at these trusts. Key messages This project highlighted the variable quality and satisfaction with feedback and learning from cases amongst staff. An anonymised bulletin of staff submissions increased access to learning, removed barriers to feedback, and encouraged a culture of positive learning from errors. The ease, simplicity, and blame-free nature of the submission process increased engagement of staff with governance, ultimately prioritising patient safety and staff psychological safety concurrently. This project has demonstrated a successful, manageable method of expansion and scalability and shown reproducibility at multiple sites within a subspecialty. Continued interest from sites nationwide demonstrates enthusiasm for further expansion. Next steps involve implementation in other specialties by obtaining buy-in and supporting set-up. Finally, local bulletins ensure learning remains highly relevant to its readers and distribution is within a psychologically safe environment. However, local bulletins should be reviewed periodically to identify regionally and nationally relevant cases and pave the way for a national-level bulletin.