Evidence Bites: Patient safety evidence summaries

The Library & Knowledge Service produces evidence summaries following the weekly Trust-wide Safety Summit which are disseminated across the organisation.

During which period did you implement you innovation?

August 2017

What was the driver for your innovation?

The Trust’s new Medical Director initiated a weekly Safety Summit following a series of patient safety concerns across the organisation. The purpose of the event is to identify rapid learning or actions following serious incidents which have occurred during the previous week to be shared with the wider organisation.  There is an opportunity for all members to contribute issues to explore during the summit. The event is very informal and takes a “no blame” approach. It runs in addition to the Root Cause Analysis process which takes up to 60 days to investigate and report.

What did you do?

Following each Safety Summit LKS staff liaise with the Medical Director and Risk Manager and agree a topic for an evidence summary.

LKS staff produce a one-page evidence summary, the “Evidence Bite” on the same day that accompanies a “Safety Bite” bulletin produced by the Risk team.  Both bulletins are disseminated to all staff via a global email sent by the Medical Director.

The Evidence Bite is a one-page evidence summary that is deliberately concise and accessible. It covers a topic that directly responds to the patient safety concerns raised at the weekly Safety Summit.  It may be in response to an individual clinical incident (e.g. patient inadvertently exposed to harm while in surgery) or it may relate to a wider and recurring safety concern (e.g. incorrect identification of patients). 

The content of the Evidence Bite may include:

• Good practice in other NHS Trusts
• Effectiveness of a patient safety initiative
• Literature around barriers to staff uptake of a safety mechanism
• Benchmarking our processes against safety standards or other organisations

Evidence Bites that the LKS has produced so far include:

• Druggles
• Distractions and interruptions
• Extravasation
• Mental capacity assessment
• Patient identification
• Red bag imitative
• Safety checklists in radiology

What methods were used to evaluate your innovation?

LKS input into the Safety Summit has been evaluated through actively seeking feedback from the other teams involved in the initiative, including the Medical Director, the Risk Manager and Director of Pharmacy and Medicines Management. 

What were the outcomes and key learning points?

Producing a concise evidence summary within 24 hours has enabled members of the LKS team to develop and practise their searching, summarising and synthesizing skills.  These skills are applied in other areas (e.g. via our standard literature searching service) which has enabled us to improve the quality of the service. 

The LKS is seen to be an integral, informing and extremely responsive part of a key safety process which is highly valued by the Medical Director, Risk Manager and other senior colleagues.

Learning, best practice, benchmarking and summaries of evidence, produced by LKS and endorsed by senior managers are swiftly disseminated to all Trust staff, speeding up change, innovation, learning and enhancing patient safety.

The Evidence Bite on “Druggles” (drug safety huddles) has resulted in Druggles being initiated within the Trust led by Pharmacy and shared with our Trust-wide Quality Improvement Network.

The LKS wasn’t approached to provide this support; we produced the first Evidence Bite uninvited and presented it to the Medical Director.  She was impressed and asked us to produce an Evidence Bite every week.  Our learning from this is that being bold and opportunistic in our approach to senior managers can pay off!

Please provide a short quote from a member of staff who has benefitted from the innovation

“I find our library and knowledge service really helpful and very responsive. We were discussing the implementation of druggles (medicines safety huddles) and wanted to understand the evidence base. In next to no time the search was in my inbox! The information provided helped persuade those who were unsure of how the concept could benefit them by providing clear information on what druggles were and the experience of users to date.”  - Pippa Roberts, Director of Pharmacy and Medicines Management

“The introduction of the weekly Evidence Bites Newsletter that is distributed Trust wide to support the topic(s) that have been discussed has proved very popular and is viewed as an excellent source of information. It also enables the information to be available to staff who have not been able to attend the weekly Safety Summits.” - Yvonne Erikson, Risk Manager

Submitted by Victoria Treadway, Library and Knowledge Service Lead, Library and Knowledge Service, Wirral University Teaching Hospital NHS Foundation Trust