{
  "abstract": "Background Patient safety is the avoidance of unintended or unexpected harm to people during the provision of health care (NHS England. The NHS patient safety strategy. [internet] 2019). Reporting incidents allows staff to learn from mistakes and change practice where needed (NHS England. Learning from patient safety events. [internet]).Aims To identify an effective way in externally sharing serious safety issues identified by patients admitted to the hospice from the community or another organisation, including any Care Quality Commission reportable incident plus safeguarding concerns, extensive pressure damage and medication incidents (Care Quality Commission. Regulations for service providers and managers: Regulation 18: Notification of other incidents. 2023 [internet]). To provide feedback, identify poor practice and enable learning in a more thorough, robust way.Methods A working group was formed consisting of, In-Patient Unit and Community leads, Pharmacy and admin. Incidents are reported via our hospice reporting system (Vantage) and serious clinical incidents result in an investigation (NHS England). An escalation form has been developed in addition and shared with the relevant organisation. All incidents are discussed at our governance meetings and learning is disseminated via our newly developed hospice learning log.The Patient Safety Incident Response Framework (PSIRF) (NHS England. Patient Safety Incident Response Framework [internet]) recommends an emphasis on involving those involved in incidents, to understand their experience, so initially we liaised with Community and Acute Hospital patient safety leads, to identify our intentions and establish engagement. A ‘learning from incidents’ escalation form was developed, reviewed, agreed to be used and is currently in use for escalating any serious incidents externally.Results The form is now being widely used and feedback has shown that further investigation is being done by the organisations that we share this information with.Conclusion As PSIRF is becoming more familiar and emphasis is on learning and improving practice after an incident has occurred, the ‘learning from incidents’ form and learning log complements this. We are now focussing on SWARM huddles and early identification of learning from incidents specifically in our In-Patient unit.",
  "authors": [
    {
      "affiliations": [
        "St Gemma’s Hospice, Leeds, UK"
      ],
      "name": "Laura Speight"
    }
  ],
  "title": "P-89 Learning from incidents",
  "uid": "5542647a-733e-560d-a2c9-5cc97563677d"
}