At the same time, adverse incidents should be investigated to see what lessons can be learned in order to improve the quality and safety of patient care.
Areas of risk
- Administrative lapses – such as failure to follow up referrals.
- System failures – such as lax data security protocols leading to inadvertent breaches of patient confidentiality.
- Clinical lapses – failure to monitor patients for periodontal disease; failure to take radiographs of diagnostic quality at recommended intervals.
Effective risk management is a five-stage process. It involves:
- identifying areas of risk within the practice
- assessing those risks for frequency and severity
- removing those risks that can be eliminated
- reducing the effects of those risks that cannot be eliminated – implementing risk-containment processes
- weighing up the costs of risk – getting it right versus getting it wrong.
Set out a written protocol which states the processes for handling routine and non-routine activities, such as infection control, hospital referrals or raising concerns. Store these documents in a folder and make them available to all members of the dental team, to help them achieve a common understanding and consistent working practices.
Risk reduction processes should be audited at intervals. Make any appropriate changes following reviews, so that you can be sure you are meeting current standards and practice needs.
Practices should gather information about the safety and quality of their service from all relevant sources, including incidents that have, or could have, harmed patients. These should be investigated and, if appropriate, considered as part of a significant event audit to identify the causes and implications for patient safety. A system for recording and reporting patient safety incidents is a GDC requirement.
Focus on the learning points from investigations and audits so practice systems and training can be improved to protect patients from unsafe care.
The National Reporting and Learning System (NRLS) is part of NHS England and enables practices in England and Wales to report adverse events which could have, or did, lead to harm for a patient receiving NHS-funded healthcare. Practices in England have a statutory duty to notify the Care Quality Commission (CQC) of a death or serious injury to someone using their service.
What is a significant event audit (SEA)?
An SEA is a way of formally reviewing incidents at your practice using a structured root cause analysis to determine what happened and why, agree what lessons need to be learned and take the necessary action to provide better patient care.
SEAs are ideal for analysing more complex cases which have implications for the overall quality of care, particularly system failures (rather than one-off mistakes by individuals).
An SEA meeting can be useful to allow others in the practice to contribute. Such meetings require careful preparation and protected time in order to be effected. If it is decided that further action is necessary, a designated person – such as the practice manager – should agree an implementation plan with relevant staff which prioritises required changes, identifies a project leader, establishes a timescale and outlines the timing of progress reports.
Keep a detailed, written record of the SEA so that you can demonstrate it was completed satisfactorily. Anonymise information to protect patient confidentiality.
This guidance was correct at publication 17/07/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.