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Hiba Ahmed
NHS trust, The United KingdomTitle: Stop the Line Initiative in Hull Neonatal unit (Reporting and Learning from Near Misses)
Abstract
‘Stop the Line’ is a well-known control
mechanism with the primary aim of promoting patient safety. All members of
staff are encouraged to ‘Stop the Line’ if they notice a series of
steps/process that could potentially cause harm to a patient. The
event/incident that is stopped is referred to as a ‘near miss’.
The intention is that any staff member,
irrespective of role, grade, seniority, or experience, can call ‘Stop the Line’
if they see that required safety procedures and checks are not being followed.
Patient safety experts argue that the root
causes of near misses and adverse events are similar. [1,2]
Therefore, detecting root causes of near misses can help us to correct these
causes and prevent future adverse events. The goal of a reporting system is to
identify and remove the root causes of incidents (not merely counting the
events) and this can be achieved by near misses. [1]
Methods
This initiative rolled out to the Neonatal unit
in Hull teaching hospital NHS trust Mid November 2021. Posters were developed
to educate staff on what near misses were and promoting ‘Stop the Line’
reporting through either the DATIX system or paper reporting forms.
Near misses reported were shared as lessons
with staff without guilt and blame culture that may be associated with other
types of incidents.
-Initiative introduced to senior nursing staff
in Band 6 meeting and to nursing educator lead and information distributed to remaining
nursing staff.
-Initiative presented to NICU consultant
business meeting and on grand round where all medical team made aware, educated
on near misses’ definition &how to report them.
Results
This is currently work in Progress.
-Six near misses reported since start of pilot
period for this project.
-Four of them related to medications and
prescription so Pharmacy team involved in the initiative for future reporting
and lessons sharing.
-All learning lesson shared with team and
reporters praised for been patient safety advocate.
-Ongoing Staff education and encouragement to
report near misses and lessons sharing.
Conclusion:
Reporting near misses is one of the practical
solutions to the perplexing problem of patient safety.
Evidence suggests that the culture of patient
safety and the characteristics of errors may have a significant impact on
reporting.
Biography
Hiba Ahmed has graduated from university of
Khartoum, Sudan in 2014, Completed two years of postgraduate pediatrics
training as part of IMGT training initiative in Ireland 2018-2020 and obtained membership of Royal College of Pediatrics
and child Health in February 2020. She is Currently a pediatrics SPR in the
United Kingdom, East Yorkshire Deanery. She has been the chief registrar in her
trust for the year 2021-2022.Has a recent Publication of a case report in Infant
journal.
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