Healthcare professionals must be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. As part of our requirements under the duty of candour guidance this also includes involving patients or residents who have developed a pressure ulcer in the investigation.
How much you involve these experts by experiences depends on the case and factors such as if they have capacity, a recorded advocate, or lasting power of attorney (LPA) who should be notified instead.
For those that haven’t seen Richard’s story with his wife Doreen, follow the link below. I often use this clip in my training.
Where there has been an acquired pressure ulcer for category 3 or 4, long term care organisations are required to complete an internal root cause analysis to identify contributing factors, root cause, and establish if there are any gaps in care.
In an instance when we find gaps, more often than not, actions are set with change implementation to follow. Whether or not these actions are measured for suitability and sustainability can vary greatly between groups.
As I mentioned, Under the Mental Capacity Act (MCA) and Duty of Candour we must inform the patient of the incident. How much we involve them in the process can vary. Involving the patient can at first be difficult, as if there are clear gaps identified we may feel we have failed our patient in some way. It may also be difficult to be transparent about strains we are under that may have contributed to the harm.
A solicitor who deals with medical claims said to me that “One is more likely to litigate against a good organisation that hasn’t communicated with them on harms than a poor one that has involved them from the beginning.” The feedback I have had from my cases over the years was that, although they were not happy with the service they received, if they have been involved in the investigation they felt it was being treated seriously. The patient can see that in most case any neglect is Rarely malicious and more often than not, they can be part of the solution.
This is of course a lot easier said than done and can take awhile for this process to become second nature and part of all QI actions following harms.
Staff culture and behaviours for those that know me know this is a subject I follow with great interest, the reason being this issue raised under this section of the RCA comes up again and again. From one member of the team not feeling it was there place to take action on suspected skin decline, to negative organisation behaviours which have a negative effect on all staff. All of which in turn have a direct impact on patient safety. We have all seen the big cases around this such as the Francis report, where multiple failings where found.
The below infographic from the safeguard lead at NHS England is a great visual descriptor of the complaints it takes to instil behaviour change.
You will see there is no one acton or quick fix that is recommended, however this can be used as a reference to come back to where some of your work to tackle this areas is struggling.
How we pick up the baton to include a resident as an expert by experience can vary, there is no one fits all approach that will match each organisation, however I have listed below from my experience an algorithm to benchmark too. I hope this helps:
- Identified Multiple category 2, 3 or 4 pressure ulcers
- Follow internal procedures for reporting harms
- Follow aSSKINg plan to ensure plans in place
- Follow duty of candour protocol and inform of internal RCA
- Begin RCA
- Identify Contributing factors and Root Cause
- Invite resident of advocate to attend reflective panel to hear outcome and discuss any action plans
- 6-8 weeks review action plans and measure fro feedback and efficiency
- Share any learning across the home or organisation
- Celebrate any changes that have be sustained and improved practice
If you or your organisation need any support with training on Root Cause Analysis investigations incorporating how to support the above, please contact Faith Slater RN, OSKA’s Clinical Support Nurse.