Integrating Risk Management & Moving & Handling

Richard HinckleyHead of Patient Safety & Risk Management, King’s

College London NHSFT

Simon WellsMoving & Handling Manager, King’s College London

NHSFT

Systems for identifying Safety Issues

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Safety Issues

Reactive

Reactive Proactive

Proactive

External External

Internal Internal

External inspections/ assessments (NHSLA, CQC, HSE)

Safety notices (MHRA, Rule 43 etc)

Benchmarking (eg. via inpatient surveys)

Performance targets

Risk registers & Board assurance Framework

Internal benchmarking (surveys, patient experience)

Risk Assessments & Observational audit

Internal inspection & audit

Complaints Incidents ClaimsPALSInquests

National guidelines (NICE), NCEPOD reports etc.

Trends from national reporting (NRLS)

Identifying & Managing Safety for M&H

Focus on 2 specific systems:•Reporting & managing incidents allows processes to be changed to stop incidents recurring & prevent potential harm turning into actual harm•Observational audit permits assessment of actual practice & real-time feedback. Training & equipment deficits can be identified & addressed immediately

Identifying & Managing Safety for M&H

1. Incident management– Reporting systems– Investigations– Ensuring improvement

2. Observational audit– Format of audit– Integration of improvement into local practice

Incident ManagementAn effective incident management system will:•Identify a wide range of risk issues in sufficient detail in a timely way•Triage risk issues according to seriousness (prioritisation & proportionality)•Investigate incidents in a structured way (RCA)•Engage local teams to ensure learning is embedded into practice •Feed into local governance systems to ensure learning is sustained

Incident Management: Reporting• Online reporting form (with drop-downs):

– Easy to complete– Provides instant reference number– Allows emails to be auto-generated (eg. to M&H

team)• Web-based system

– Access to system flexible – allowing designated staff to see incidents details, investigation progress & action plans

– As M&H team alerted to all AIs with type = M&H, can respond immediately

Incident Management – Reporting • A successful reporting system should consider:

– Identification of risk leads within clinical departments (need clinical buy-in from outset)

– Staff training (need training programme & resource to deliver it)

– Form design (must be user friendly – user testing)– Responsiveness to departmental needs (this should be

tempered by need for minimum data)– Feedback to staff (if not possible via system, then via

cascade from risk meetings, newsletters etc)– Corporate focus (duty of all staff to report AIs)

Incident management – investigation

• All incidents “approved” by Risk Manager or delegated risk lead in clinical area. Involves assessment of seriousness

• Level of investigation determined by seriousness– Incidents with moderate harm = investigation report– Incidents with major harm/death = full investigation

• Use of Root Cause Analysis (RCA) helps identify structural (rather than personal) causes

Incident Management – Investigation

Indicate whether the event directly led to harm, did not directly lead to harm, or whether the event was prevented from occurring.

If harm was caused, then an additional field will appear asking for the degree of harm. The help icon will provide guidance on what each option means .

Incident Management - InvestigationEffective incident investigation involves: •Structured approach to investigations

– standard investigation templates– use of specific RCA tools (5 whys, After Action Review,

timeline, wishbone etc)– clear deadlines & reporting structure• Pool of trained local clinicians that can be

tapped into (M&H link worker programme; investigations training programme)

• Quality of investigation (& findings) reviewed at local and Trust risk meetings (M&H input)

Incident Management – ImprovementSustained improvement via investigation involves:•Local ownership of action plans (clearly identified local leads with deadlines)•System for monitoring

– Tracking of actions via local committees– Periodic review of implementation (link to NHSLA)– Scorecards– Link to Trust audit programme

•Shared learning (newsletters & reports, events to raise awareness)

Example: M&H Incident (1)• Sedated neuro patient fell to floor during transfer

between operating table & bed post-surgery• No incident form completed (M&H team

informed later by theatre link worker)• MH investigation revealed bed brakes not

applied & no patslide used during transfer, surfaces parted & patient fell

• Outcome: bespoke training for local area - reinforcement that equipment must be checked & patslides used & AI completed. Without link worker investigation wouldn’t have occurred

Example: M&H Incident (2)• AI - Back injury due to carrying heavy back pack

during transfer of patient from ward to x-ray• M&H advisor assigned investigation which

identifies as nurse (with backpack) walked through lift entrance, doors closed trapping the back pack and pulling the nurse backwards. Back injury resulting in time off work & light duties when she returned

• Incident due to lift door pressure sensors not working properly & open doors automatically

Example: M&H Incident (2)Investigation findings & actions:•Pressure release locks on certain lifts not working - problem known to Estates but never reported to other staff groups (so not acted upon)•Lift mechanism investigated and repaired by Estates post-incident•Service managers now aware of issue & workers informed•Review carried out of how back packs can be carried or supported on bed during transfers

Example: M&H incidents (3)• Issue: clinical staff experiencing back pain (esp.

theatres). Identified via AIs & feedback at training• M&H Investigation

– Risk factors (frequency, route, cumulative strain, poor work practices by porters)

Outcome:• Change in training for porters• Purchase of 4 powered bed movers for porters• Reinforce at MH training how to move beds

M&H Observational Assessment

Back ground•Wanted to supplement yearly audit of MH equipment in clinical areas•Some way of collecting ‘live info’ on what workers really doing in practice when MH patients•Simple, easy to complete system•Easy format to feedback to respective divisions at Risk & Governance meetings

Information collected• M&H incidents (AIs) reported in area, & of these no.

resulting in WRMSD• No. of workers on Long Term Sickness absence due

to WRMSD• M&H equipment available against M&H Equipment

Standard• % workers with in date M&H training• Assessment of Moving & Handling activities in the

workplace– Patient handling activities– Load handling activities

Assessment of MH activities in the workplaceA] Moving & Handling Activity: standing, sitting, hoisting

(Indicate the handling activity assessed by ticking against technique) sit – stand from bed/chair/commode/couch to stand ( )stand – sit on bed/chair/commode/couch ( ) repositioning in the chair ( )walking ( )hoisting transfer ( )

(Comment if technique altered due to patients condition or situation)

Patient RA form completed(circle Y or N)

Safe technique/handling principles identified(circle Y or N)

No. of staff required correctly identified(circle Y or N)

Equipment identified correctly(circle Y or N)

Good application of technique(circle Y or N)

Total Score

Y / N Y / N Y / N Y / N Y / N

General comment:

B] Moving & Handling Activity: Movement of patient in bed:sitting forward ( )rolling/turning ( )proning ( )move up bed (supine transfer – dependant patient) ( )lateral transfer ( )

C] Moving & Handling Activity: Personal care:transfer into bath/bathing ( )transfer into the shower/assisted shower ( )dressing ( )

Findings from Neuroimaging AssessmentFindings & actions:•Equipment available (eg. for lateral t/f) but not used correctly (attendance at dept. to identify better use of equip)•Consultants had not attended MH training (focussed M&H training session arranged)•Equipment required to take testing equipment into domestic environment (folding trolley identified & procured)•No M&H link worker (worker identified & training booked)

Summary• Years programme of M&H Obs. Assessments in

clinical areas • ‘Live’ information & timely delivery to the

coalface• Additional information for use in training room• Feedback on impact of training in the workplace• Additional information on level of compliance

with Trust MH Equipment Standard (2009)• Link to incident trends