Summary

The Significant Clinical Incident Forum (SCIF) is a novel multi-professional group that investigates clinical incidents and untoward clinical outcomes throroughly and independently with the aim of fostering an open culture towards clinical incidents and disseminating learning from care episodes as widely as possible.  

The multi-professional nature of the team enables it to work with all professional groups at the Cancer Centre.  SCIF investigations have resulted in clear benefits in patient care/outcomes and also to specific inter-professional sharing events that enable colleagues to learn from incidents and help reduce future incidents.  

It has had a major impact on patient care and education practices in the Velindre Cancer Centre and within the Cancer Network with measurable improvements in patient care.

SCIF has worked with colleagues in Primary and Secondary Care across the Cancer Network, developed links with local GPs regarding assessment of chemotherapy patients in the community and created local guidelines for GPs in this area. It has organised an inter-disciplinary learning session on spinal cord compression, resulting in the development of a specific educational workbook and a network wide referral guidelines.

Challenge

Cancer treatment is complex and potentially hazardous. There are huge variations in the patient population treated in terms of age, disease burden, existing co-morbidities and social support. Systemic anti-cancer therapies and radiotherapy have specific risks and toxicities that demand tight control and monitoring to ensure patient and staff safety. 

Prior to the SCIF, no formal reporting system existed for the majority of patients who were being treated routinely in the Velindre Cancer Centre. Incident forms were being filled in but rarely by clinicians themselves and there was no clear system for dealing with these incidents and learning from them. 

Allowing professionals to raise concerns about care in a safe environment is crucial and the introduction of SCIF has allowed this to happen. The independent review of cases, with timely, in-depth feedback and clear recommendations about future care has helped cultivate a culture of openness and support. The ‘no blame’ approach and focus on lessons learnt has been key to preventing the repetition of problems resulting in a safer patient environment.

The SCIF team, chaired by a Consultant Clinical Oncologist, comprises health professionals from diverse groups all of whom contribute to discussions/investigations. Other groups are invited as appropriate, including GPs, surgeons and radiologists. The group links in with all other professionals at Velindre Cancer Centre and also with colleagues across the SE Wales Cancer Network, including both Primary and Secondary Care so the care of cancer patients can be evaluated in all localities. 

The group was formed in 2007, since which time it has grown and developed into a crucial part of Velindre Cancer Centre where it drives improvements in patient safety and informs educational programmes for the Cancer Centre and Regional Cancer Network.

Ensuring that education programmes are based on these clinical incidents/specific care episode investigations links clinical governance and education. In turn this results in medical education that it focuses on topics central to good patient care, which are directly relevant to both healthcare professionals and patients and can help staff learn from others’ to prevent repetition of problems and improvements in patient care/outcomes. It has also engendered a multi-disciplinary team approach to such events that has reduced the culture of individual blame when things go wrong.

Before the group was established, clinical incident referrals by clinicians were made infrequently. There was no formal process for multi-professional detailed investigation of incidents and there was no means for reviewing care following an adverse outcome in the absence of a specific clinical incident, for example worse than expected chemotherapy toxicity despite appropriate dosing and management. 

There was also a lack of formal education activities or methods to disseminate lessons learnt from incident investigations, resulting in repetition of problems and limiting opportunities to learn and improve in clinical care.

Objectives

The objective was to improve the whole process of clinical incident investigations across the Cancer Centre and to link these investigations to high-quality education activities to disseminate learnings from clinical incidents as widely as possible. It was important to have a consultant oncologist as the lead to improve medical staff involvement into such issues.

The following objectives were set for the group:

• Reporting: A systematic process of reporting of incidents to the group needed to be established and encouraged, through both awareness of the groups role; the openness of investigation and the thoroughness, timeliness and quality of reports
• Investigation: A truly multi-professional group to investigate clinical incidents/untoward events in a blame-free environment was deemed essential in order to cover all aspects of incidents; to encourage referral of events to this group; to circulate findings both to those involved directly and to a wider audience 
• Recommendation: To set clear recommendations from each incident based on lessons learnt and to support those responsible for ensuring these actions are carried out, highlighting any good practice and near misses in the process
• Education: To develop strong links between investigation work and educational events to disseminate learning and information sharing as widely as possible within and outside of the Cancer Centre and to encourage reporting through the quality of the educational materials. Investigations are used to develop local/regional teaching/education materials so professionals can learn from incidents to help reduce their frequency. Another important objective was also to share evidence of good practice as a way of improving patient care.  

We also wanted the group to be able to reach outside of the Cancer Centre when necessary – either to investigate incidents related to cancer in regional hospitals or to help with education across the Cancer Network.

Solution

Based on systems already in place at the Cancer Centre, a group of healthcare professionals was chosen to represent all professional groups. Training was provided in incident management/investigation to enable the group to perform its functions professionally and thoroughly. Terms of reference were written and regularly reviewed as the group’s experience, role and composition broadened.

Members include: 

• Clinical oncologists (consultants and trainees)
• Nurses
• Patient safety co-ordinator
• Clinical change facilitator
• Pharmacists
• Radiographers
• Dieticians 
• Infection control team members
• An education lead and general management and administrative support.  

Core team members lead subgroups set up from investigations to ensure that changes are made, implemented and audited.

The core group is responsible for reviewing each incident referred and deciding on what further action is necessary. For example, in- depth root cause analysis (RCA) or an exploration interview with the staff involved. Monthly meetings are held with the larger team where the RCAs are presented to a multi-disciplinary forum with the relevant personnel and expertise present. The group’s role and remit are advertised widely around the Cancer Centre to raise awareness. 

A number of effective ways to disseminate the SCIF outcomes have been devised.   

The objectives are met in the following way:

• Reporting: Incidents are identified through a number of mechanisms: 
• A weekly mortality review of all deaths within VCC, 
• The Global Trigger Tool audit (a 1000 Lives Plus initiative), 
• Direct staff reporting and 
• Online incident reporting via Datix, which is escalated to SCIF by departmental managers. 
• Investigation: Incidents/events are investigated thoroughly using established methods such as the fishbone model, RCA including interviews with those involved and thorough review of case notes/electronic records 
• Recommendations: These are set and agreed during the monthly multi-disciplinary meetings. Standards of care, hospital policies and guidelines have been reviewed or developed along the way. A traffic light flagging system is used to follow-up recommendations and ensures that follow-ups are carried out in a timely fashion
• Education: Feedback is given personally to individuals involved and more widely within the Cancer Centre, eg, through a speedy cascade of suggestions (emailed to all staff immediately after meetings) and through specific educational events. Quarterly ‘open meetings’ are held within the Cancer Centre to reach a wider audience and share lessons learnt. These sessions may include a patient group representative as well as colleagues from Local Health Boards. A safety first newsletter is also released quarterly highlighting the relevant news and feedback. The team felt it was important to highlight examples of good practice, as well as other learning points. Historically, feedback is only given when problems have arisen but there is often much to learn from seeing examples of good clinical care.  

A diagrammatic summary of the SCIF process

Results

The themes from 2011 data are shown below. During the 12-month period from December 2010 to November 2011 (inclusive), 36 incidents were referred, investigated and discussed by the SCIF MDT forum. Over half of these incidents involved acutely unwell patients and Clostridium difficile infections.

Fig.1 2011 SCIF referrals classified according to themes

The majority of referrals come directly from consultant oncologists (50 per cent), 25 per cent come from other staff, 14 per cent from the weekly inpatient mortality reviews, 4 per cent from the Global Trigger review (monthly case note reviews using methodology for identifying harm) and 1 per cent from Datix (online reporting system). This referral pattern is in contrast to the Datix system which clinicians themselves are less likely to use for reporting incidents.

For each of these SCIF themes, a thorough investigation takes place, after the initial review by core members. The following recommendations and initiatives have been carried out directly as a result of the SCIF process:

• Infection (22 per cent): Renaming of the neutropenic policy following non-neutropenic sepsis, which was not recognised. Education on the Sepsis 6 Tool was rolled out to junior ward doctors and nursing staff
• Clostridium difficile outbreak: Significant review of the Centre’s antibiotic policy including removal of prophylactic antibiotics from chemotherapy regimens. Initiation of recording antibiotic start and stop dates on inpatient prescription charts to avoid prolonged use of antibiotics
• Chemotherapy toxicity (33 per cent): Use of a consistent common toxicity criteria for grading toxicity in all documentation to avoid inaccurate reporting and subsequent failure to respond to high-grade toxicities. Also, standardising advice for chemotherapy pager holders, a 24/7 telephone service for all patients or carers with chemotherapy queries
• Cord compression (14 per cent): A number of cases of missed clinical signs of early cord compression have led to an important SCIF-led workshop at a Network level to implement joint working practice, guidelines, a workbook tool and a patient information letter and smart card.
• Chemotherapy related chest pain (8 per cent): A protocol for managing chest pain during cardiotoxic infusional chemotherapy has been developed including a policy to perform routinely baseline ECGs prior to these infusions 
• Paracentesis and chest drains: Several incidents involving these procedures highlighted that there was no adequate policy in place. Safety measures such as pre-procedure bloods including clotting screens, use of radiology where relevant have now been stipulated clearly in accessible protocols.

A variety of methods are used to disseminate findings:

• High-quality written and verbal reports are created, with individual/personal feedback to those involved (both to support them and offer guidance)
• Rapid cascade emails are sent after each meeting, outlining some key points that are important to highlight quickly. These are sent to all professionals working in the Cancer Centre within 48 hours of each SCIF meeting to disseminate key discussion points. Feedback on these emails is extremely positive
• Updates are also given at regular consultant meetings and inter-disciplinary systemic therapy teaching sessions to help keep senior and junior medical staff and specialist nurses informed of investigations and to further share important educational elements from the investigations
• Specific education sessions have been organised on chemotherapy toxicity management (capecitabine); spinal cord compression (including writing network guidelines, patient information letters and card); guidelines and education for GP management of febrile patients after chemotherapy has been developed with the input and co-operation of GP Out of Hours colleagues.

Evaluation

• Culture shift within the Cancer Centre: a steady increase in consultant and nursing reporting of Incidents to SCIF over the years
• Feedback from the open sessions and from individuals: managers and consultants involved, and patients through use of patient stories. (See resources).
• A reduction in the adverse events recorded over a period (see Figure 2) 
• A reduction in C difficile infections (see Figure 3).

Figure. 2 Velindre Cancer Centre adverse event rate, calculated using the oncology global trigger tool

Fig. 3 Velindre Cancer Centre C. difficile cases per ward during a 12-month period

Impact

• The development of new policies and guidelines: management of hyperkalaemia, hypoglycaemia, paracentesis and chest drain policy, ambulance transfer policy.
• The revision of existing guidelines: management of neutropenic patients within the Cancer Centre and in Primary Care. The existing guideline was revised into a pathway for the complete management of the neutropenic sepsis, incorporating the MASCC Tool, Sepsis 6 and the antibiotic policy
• A network-wide, multi-disciplinary education session on spinal cord compression was held after cases on this topic were investigated. An educational workbook has been written and used; network referral pathways have been developed and a ‘spinal cord compression’ letter and emergency contact card have been introduced to routine clinical practice (in accordance with NICE guidelines)
• Formal feedback from the open sessions
• Personal recommendations: consultant colleague, trust board and deanery feedback statements are attached as supporting information
• Individual feedback from staff members involved in incidents/events
• Culture survey undertaken by National 1000 Lives Programme Team.

The team has started to reach outside the Cancer Centre on a more regular basis. Recent investigations into care of patients with febrile neutropenia involved GPs, which proved very informative and helpful. This resulted in GP Out of Hours protocols being re-written and education being tailored to them. 

The spinal cord compression education meeting included spinal surgeons, radiologists and medical colleagues from across the Cancer Network. The team is looking to strengthen links with regional hospitals especially the tertiary referral ITU team. It is now assisting with induction for new medical staff at regional DGHs to improve knowledge and communication. SCIF team members are also leading in regional developments in Acute Oncology projects across the Cancer Network.  

The model of investigation, discussion, feedback and education could be adopted by other healthcare organisations both in oncology and in other specialities to replicate the benefits seen from this approach.