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Objectives Rapid responses to incidents are undertaken to ensure timely investigation, learning and swift implementation of change to avoid recurrence.1 Incidents are often analysed in isolation and recurring issues are not explored with the wider multidisciplinary teams. Junior doctors and nurses may be less engaged with learning about governance and patient safety processes, viewing it as a role for those in more senior positions.2 We aimed to look at the themes generated from 'incidents requiring investigation' (IRIs) within acute paediatrics with a view to improving how the wider team engage with patient safety processes. Methods This is a retrospective analysis of all IRIs that occurred over one year in a district general hospital. Common themes were grouped, and outcomes explored. Results Over one year there were 32 IRIs. Themes identified included – patients re-attending within 48-hours of discharge and going on to require HDU/PICU care 19%. Failure to recognise and/or appropriately escalate the seriously unwell patient 44%, child brought to hospital requiring active cardiopulmonary resuscitation (and subsequently died) 31%, diagnostic delays 9%, significant drug error 3%. 'Communication' was repeatedly featured as a core issue in round table discussions following IRIs – and noted to be either a leader's and/or teams' strength or weakness. Hot debriefs were conducted for 44% of incidents. 6% were declared as 'serious incidents' with other outcomes being 'local learning' or 'no further action'. Conclusion Empathetic leadership, timely debriefs and addressing system failures early are vital to supporting colleagues throughout incident investigation. Similarly, ensuring that duty of candour is completed and that families are supported throughout the process. Our team benefited from 'round table' discussions as a reflective deep dive into incidents, making team members feel heard and not alone. Multiple cases with similar themes were brought to the same round table – improving participant attendance and learning. It is often senior clinical team leaders not directly involved with the case who investigate and analyse IRIs, stressing the importance of contemporaneous accurate documentation. The learning from incidents is valuable for the wider team, not for just those involved, as is learning about the investigatory process.3 More work is needed to improve the attendance of both senior and junior doctors and nurses at governance and risk meetings throughout paediatrics. References Tse Y, et al. Arch Dis Child, 2014. The Kings Fund, Leadership Review, 2012. Sarfo-Annin JK. Future Hosp J, 2015.
Gite et al. (Tue,) studied this question.