Key points are not available for this paper at this time.
Objectives The aim is to explore personal experiences around the investigation of clinical incidents and suggestions from those involved to improve engagement and learning. The intention is to inform changes to support implementation of the Patient Safety Incidence Response Framework (PSIRF). Methods Survey sent to two areas of tertiary children's hospital; General paediatric and Emergency area. Responses were anonymous. Respondents were asked for one word to capture emotion felt when involved in a safety investigation. They were asked to score clarity about purpose of the investigation, how supported they felt, how much their thoughts and experiences were heard, if they were offered a debrief and if they were shared the outcome of the investigation. After all questions, a free text section asked how each could be improved. Lastly they were asked to select top three words to improve experience. This was followed by focus group sharing the results of the survey and group discussion to explore potential actions to take forward. Results Twenty four people responded; 50% Doctors, 42% nurses and 8% allied health professionals. There was a wide range but the majority of people reflected a poor experience of understanding, support and involvement with 48% not knowing the outcome of investigations. Scared was the commonest response to involvement. Support, debrief and timelines the words mostly commonly used for suggested change. There were extensive free text comments capturing experiences and suggestions for improvement. The focus group highlighted how helpful it was to acknowledge the emotional response and know others felt the same; the desire was for a 'help' booklet created by those that had been through it, with what they wished they had known. A provisional booklet is being compiled, using the PSIRF staff engagement as a basis with further feedback planned before finalising and applying for approval. There was suggestions for changed communication and education so that there is a better understanding of safety processes by all and not only when directly involved. Conclusion The findings supported all the PSIRF changes advised to improve staff engagement and support but also identified that the emotions felt and anecdotes collected in the feedback would be a valued component of any staff resource. It being devised by people with experience of being at the receiving end was felt a powerful means of peer support. There was an ask to incorporate other safety responses including complaints into the advice with better signposting to resources to support writing responses but also local and national resources to support staff. References NHS England. Patient safety incident response framework. 2022. https://www.england.nhs.uk/patient-safety/incident-response-framework/ Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care 2010. doi:10.1136/qshc.2009.035253
Conway et al. (Tue,) studied this question.