The next top tip for safer surgery I want to talk to you about is learning through talking. By talking about adverse events, we can prevent ourselves and others making the same error again. And therefore we can improve patient care.
By discussing what happened with compassionate colleagues in a safe space, we can shared some of the upsetting feelings that we encounter and reduce the chances of burnout and those leaving the profession. In this session we will learn how to implement specific tools to learn through talking. So the first thing we need to do is identify areas for improvement.
And this can be done through a a number of ways. It can be done through word of mouth, it can be done through critical incident reports, or a clinical audit could be performed. We need to make sure that we learn from everything.
This graph shows us that where we focus our safety generally on accidents and disasters actually represents a really small proportion of our working day. And we need to accept that we need to understand the bit in the middle, and we need to understand what exceptional performance looks like and how we can gratefully accept the the good feedback. By talking about adverse events, we can prevent others making the same error again and therefore improve patient care.
By discussing what went wrong and what went right, the case with compassionate colleagues in a safe space, we could shed some of those upsetting feelings we encounter. So we learn through talking. We start by using a hot debrief tool such as stop 5.
We report our critical incidents so that we can learn from them and talk about them. And then we select cases for learning discussions and for audits. We need to understand what being a second victim is.
We know that team members feel emotionally traumatised by adverse events. And second victims can experience a multitude of symptoms that last from weeks to months to years. And they can damage their physical and emotional health, and deteriorating individual and team performance can ultimately compromise patient safety.
So we seek to understand the recovery process, so that we can monitor victims and connect them with the appropriate support resources as and when they need them. Second victim recovery occurs in 6 stages. The first stage is chaos and accident response.
At the moment that an adverse event or or outcome is detective, the involved clinician or nurse describes chaotic and confusing scenarios of both external and internal turmoil that ultimately led to the realisation about what had occurred. Stage 2 is a period of haunted reenactments, often with feelings of internal inadequacy and periods of self-isolation. The victim re-evaluates the situation repeatedly asking themselves what if?
The 3rd stage is described as seeking support from an individual from whom they trust, such as a colleagues, a supervisor, personal friend or family member. Many people in during the research found that they didn't know who to turn and it's important to have a culture of teamwork to really aid in this process. Stage 4 is when the second victim starts to wonder about the repercussions of the event, about job security, licensure, or future litigation.
And we know that stage 5 is about obtaining emotional first aid. Sometimes this can be confiding in a friend or a colleague, but sometimes it falls short, which is why it's important to signpost to organisations such as VETET and make their resources easily available. The 6th stage of 2nd victim recovery is the last stage, and this stage is moving on.
There are 3 choices when moving on from an incident. We are drop out We survive Which means we perform at the expected level but still plagued by the event. Or we thrive.
And when we thrive, it means that we've made something good come out from the unfortunate experience. We've learned from it and moved past it. So one of the ways that we know that we can reduce second victim is by using debriefs.
And there's opportunities every single day for debriefing. I really like the stock 5 framework. It's easy, simple.
And it only takes 5 minutes. It's just time for somebody to pop the kettle on. And the purpose of this confidential blame-free team debrief is to improve patient care and to deliver timely to support to team members after difficult or distressing cases.
We need to debrief the team to learn from our experiences. So that they don't play on our mind and we don't take them home with us and worry about them. And we need to be able to share our thoughts, to be able to learn from them and maintain our mental wellbeing.
By using stock 5, we summarise the case, we look at the things that went well, we look at the opportunities we have to improve. And we make a list of actions and responsibilities so that we can move on. We know that it's very important to report political incidents.
We know that it helps people understand why mistakes happened. It helps practises develop solutions which improve the quality of their care. We share our understanding through the VettSafe website so that we can, we can research how national trends and understand how to implement larger scale solutions.
And we want to support 2 victims. We also need to consider learning discussions. We know that morbidity and mortality rounds sound quite scary, but when they run in an open, non-judgmental, confidential and collaborative way to review an adverse event, they really help us understand it, and we can therefore go on and learn from it.
Through identification, presentation of a case where an adverse event has occurred, we reflect in a multidisciplinary discussion. We analyse the case and we identify the contributing factors. Therefore, we educate and improve patient safety and care.
We also know that learning from excellence is really important. By feeding back to each other why they're appreciated and what great work they've done, we learn and appreciate each other, but also share good feeling. We need to make sure that we lose learning from excellence, as well as learning from error in all of our work every day.
So we've briefly talked about learning through talking. We've talked about hot debriefs, reporting critical incidents, learning discussions. And we know that by doing this, by talking, learning through talking, we can improve patient care.
