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PSIRP

Bringing ECG expertise to every corner of the UK

Patient Safety Incident Response Plan

Effective date: 21/06/2024

Estimated refresh date: June 2025

NAME

TITLE

SIGNATURE

DATE

AUTHOR

James Cole

IG Officer

JFC
21/06/2024

REVIEWER

Cheryl Brown
Clinical Safety Officer
CB
21/06/2024

AUTHORISER

Michael Rowe
Operations Director
MR
21/06/2024

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Contents

  • Introduction
  • Our Services
  • Defining our patient safety incident profile
  • Defining our patient safety improvement profile
  • Our patient safety incident response plan: national requirements
  • Our patient safety incident response plan: local focus

Introduction

This patient safety incident response plan sets out how Broomwell Healthwatch intends to respond to patient safety incidents over a period of 12 to 18 months. The plan is not a permanent rule that cannot be changed. We will remain flexible and consider the specific circumstances in which patient safety issues and incidents occurred and the needs of those affected.

Because Broomwell Healthwatch is not directly patient facing, our work under the PSIRF may often be in support of investigations being undertaken by other parties (GP surgeries, ICBs, etc) who use our services. Broomwell undertakes to support all such investigations fully and to the best of our ability.

There is, of course, also the potential for Broomwell to need to investigate incidents under the PSIRF where Broomwell’s own actions have negatively affected patient safety. Broomwell has robust protocols in place to try and ensure the high quality of its work, and, having operated since 2006, has encountered and learned from a number of incidents in the past. Incidents are rare, and not every incident will necessarily require investigation. Decisions regarding the need for an investigation will be made on a case-by-case basis.

Our Services

Broomwell Healthwatch provides a range of ECG interpretation services to NHS and non-NHS customers across the UK and beyond. Although a number of different services are available, all of them can be summarised under the following pathway:

 

  1. External site performs an ECG on a patient

  2. External site transmits ECG data to Broomwell Healthwatch

  3. Broomwell Healthwatch analyses the ECG

  4. Broomwell Healthwatch returns the ECG to the external site that requested it

 

It should be noted that not all ECGs are requested by the same site that performs the test, as some customers use a hub referral system.

ECGs are returned based on agreed timeframes, which vary between contracts and, for some sites, are selected on a patient-by-patient basis depending on the symptoms and the presentation of the patient. As Broomwell Healthwatch does not have any contact with the patients themselves, the decision as to what timeframe the ECG should be returned in lies with the staff at the site where the ECG is being performed.

Defining our patient safety incident profile

Broomwell Healthwatch is not a directly patient facing organisation. The Services covered by our plan are our ECG interpretation services whereby we interpret ECGs sent to us. The patient safety incident risks for Broomwell Healthwatch have been profiled using the organisation’s existing data, including the following sources:

 

  • Incident Reports – data going back to Q1 2020 has been reviewed in order to identify any patient safety themes emerging
  • Peer Review logs – twelve months of data reviewed and trends analysed to pick out patient safety themes
  • Admin Error logs – twelve months of data reviewed and trends analysed to pick out patient safety themes
  • Staff survey – 2023 staff survey regarding patient safety reviewed
  • Risk Register – reviewed with a focus on patient safety related risks, and re-assessed in the light of the above to ensure that the risk themes identified were adequately represented

 

The gathering and refining of the above data involved the work and support of a number of stakeholders, including the Operations Director, the Information Governance Officer, the Clinical Safety Officer, the Medical Admin team manager and Medical Admin team, and the Clinician team and Call taking team in the medical centre.

Defining our patient safety improvement profile

Broomwell Healthwatch is not a directly patient facing organisation. Feedback from all stakeholders was reviewed to identify risks, and the Operations Director, the Information Governance Officer, the Clinical Safety Officer and the Medical Admin team manager agreed the profile.

The organisation has a continuous safety improvement mechanism in place which ensures that any issues are caught at the earliest possible stage, and which feeds back into ongoing improvement work to ensure patient safety.

A summary of the mechanisms the organisation operates to achieve this are:

 

  • Daily clinical review feedback – daily review of every report to check clinical quality
  • Call quality audits – periodic review of calls to ensure protocols are followed
  • Admin sending checks – daily review of every report sent
  • Periodic clinical review – annual review of each clinician’s work

 

Broomwell Healthwatch also maintains ISO 9001 and ISO 27001 quality assurance accreditation, which helps to ensure the integrity of the feedback and development process.

Feedback and improvements are discussed and progressed through:

  • Security Forum
  • Management Meetings
  • Internal IG Meetings
  • Change Management process

Our patient safety incident response plan: national requirements

Patient Safety Incident Type
Required Response
Anticipated Improvement Route
Incidents meeting the Never Events criteria
Support the PSII (patient safety incident investigations) at whichever site the Never Event occurred at
Participate in the PSII and feedback any learning actions into management meetings to incorporate into the quality improvement strategy
Death thought more likely than not due to problems in care (incident meeting the learning from deaths criteria for patient safety incident investigations (PSIIs))
Support the PSII at whichever site the death occurred at
Participate in the PSII and feedback any learning actions into management meetings to incorporate into the quality improvement strategy
Death or incident thought more likely than not due to an incorrect ECG report provided by Broomwell Healthwatch
Support the PSII at whichever site the death or incident occurred at
Participate in the PSII and feedback any learning actions into management meetings to incorporate into the quality improvement strategy
Safeguarding incidents
As per Safeguarding Children and Adults Policy
Outcome of safeguarding investigation to feedback any learning actions into management meetings to incorporate into the quality improvement strategy

Our patient safety incident response plan: local focus

Patient Safety Incident Type or Issue
Planned Response
Anticipated improvement Route
ECG misinterpreted
Ongoing improvement on a continuous basis via daily clinical review of every test
Where necessary, feedback learning actions into management meetings to incorporate into the quality improvement strategy
Error in sending result back
Ongoing improvement on a continuous basis via daily Admin checking process
Where necessary, feedback learning actions into management meetings to incorporate into the quality improvement strategy
Information Technology (IT) incident that causes potential patient safety risk
PSII
Where necessary, feedback learning actions into management meetings to incorporate into the quality improvement strategy
Any safety incident that is likely to cause patient harm and is not covered by the routine audit processes described above
PSII
Where necessary, feedback learning actions into management meetings to incorporate into the quality improvement strategy

Broomwell Healthwatch

Broomwell Healthwatch is the UK’s leading ECG interpretation service for NHS primary care. We provide 24/7/365 consultant-led ECG analysis for GP surgeries, hospitals, MIUs, and walk-in centres, with over 2.5 million ECGs interpreted to date.

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Phone

0161 236 0141

Email

health@broomwell.com

Head Office

17-21 Chorlton St., Manchester M1 3HY

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