Introduction The aim of any safety reporting system is to create organisation memory by collating system errors and learning to minimise future harm. Our hospital consist of separate wards and departments each with designated investigators of incidents logged electronically. A high level nurse provides quality control and oversight after completion of reports weeks to months after the incident happened. System analysis showed our current reporting system provided variable quality reviews, inadequate feedback, long delays, poor fragmented learning and no measured improvement in safety indices.
Method Using quality improvement methodology we tested a system of daily rapid review of incidents by a high level joint medical and nursing team. Measures included resources required, disruption to existing system, timeliness of reviews, learning generated and staff acceptability.
Results Two PDSA cycles were carried out: Firstly two weeks with one nursing and one medical investigator met four times. Two to five new incidents were discussed at each one hour meeting. Subsequently a small team of senior nursing and medical investigators on a rota met three times per week for six weeks.
Time taken for completion of investigations reduced. Significant challenges were faced with imposing this new system on top of an existing but ill-defined system. Some wards had existing timely investigations but rapid review highlighted high variability in investigation quality and outcome. This QI project resulted in improved understanding of the existing microsystems and generated a wish list of additional resource requirements.
Conclusion Rapid review resulted in more timely investigations of incidents. This quality improvement project is ongoing as the biggest challenge remains improving a system by top down oversight while empowering and engaging the work done by existing staff.