Improving Patient Care and Effective Risk Management: Reporting Up 500%at Sedgefield PCT

Web-based reporting tool enables PCT staff to report and analyse incidents for a more proactive approach to improving patient safety

Sedgefield Primary Care Trust has witnessed a significant rise in the number of patient incidents logged by PCT staff since the introduction of Sentinel, a web-based reporting tool which has enabled staff to report events via NHS.net, supporting clinical governance and giving staff a greater understanding of issues to be addressed for a more proactive approach to patient safety.

Implementation of the reporting system has enabled the PCT to meet mandatory reporting requirements and provide more effective risk management through a series of early warning mechanisms.  It is also helping Sedgefield PCT to change culture, promoting a safety culture that is open and fair for sharing information and ensuring lessons are learned from patient safety incidents. 

Sentinel is a risk management tool developed by Vantage Technologies, a specialist software developer for improving working practices.  It has enabled Sedgefield PCT to record and manage incidents more effectively and conveniently, and also provides the data for analysis  to help identify incident themes and trends and improve the quality of patient care.

Sedgefield PCT’s decision to use a web-based system has enabled it to comply with guidelines and recommendations from the National Patient Safety Agency (NPSA) and requirements of the National Health Service Litigation Authority (NHSLA), Risk Management Standard for PCTs. In addition, Sentinel enables clinicians to monitor and learn from incidents to prevent reoccurrence and provide enhanced levels of patient safety. 

Sedgefield PCT was the first NHS organisation using Sentinel to be connected to the National Patient Safety Agency’s National Reporting and Learning system. Sentinel is enabling managers and the Clinical Governance Team to take a co-ordinated approach to incident reporting and analysis capturing and sharing data on a central repository to improve knowledge and reduce risks to patients.

Before teaming up with Vantage, the PCT was reliant upon a paper-based reporting mechanism run by a local Acute NHS Trust. The disadvantage for Sedgefield was that there was little ownership of the data, and information was often not acted upon in a timely manner.

Information was not being shared effectively and as a result members of staff did not have a thorough understanding of all of the prevalent themes or issues in relation to incident reporting within the PCT  – there was no systematic means of sharing information and learning from adverse events across the organisation.

333 staff at Sedgefield PCT now use the Sentinel system, including district nurses, speech and language therapists, podiatrists, health visitors, school nurses, specialist nurses and dieticians.   The system has also been rolled out to 11 GP practices across the PCT area, creating a more linked-up approach to managing patient safety incidents effectively and reducing the chances of them happening again.

Sedgefield looked at a number of options, choosing Sentinel because as a web-based solution it addressed many of the geographical and IT infrastructure issues within the Trust.  Sentinel enables PCT staff working in areas serviced by the Acute Trust IT systems to log in and report incidents remotely via NHS.net, making the process more convenient and more of an integral part of working practice. 

An additional advantage of the system is its ease of use – designed for clinicians, not for IT gurus – ensuring incidents can be easily reported and logged. Clinical staff have reported that the system is very easy to use even if staff have limited IT skills and this is reflected in the increase in the level of reporting and staff’s enthusiasm to use the on line reporting route.

Sedgefield went live with its web-based reporting approach in March 2004, and in its first full year of operation, the quantity of incident reports received has risen exponentially. The year 2002/03 saw just 56 reported incidents, whilst in 2004/05 this rose to 610, a figure which represents growth of over 1000% and which is expected to increase still further as users at the PCT gain more confidence and proficiency in using the reporting tool and see the benefits of reporting.

Deployment of the system went smoothly, and the ease of use of the Sentinel system has ensured a high acceptance level by staff, who are now more confident and vocal in their reporting. Staff also have an increased expectation of feedback from line managers about the issues raised in their reports.

The quality of incident information captured during reporting has also improved, resulting in better data management and a more proactive approach to patient safety, with generated reports from Sentinel used in a timely and meaningful manner to inform the PCT Board and various staff forums.

An additional benefit of having the Sentinel system in place is that GP Practices can report instances of patient suicide and self-harm.   Centralised data collection helps healthcare professionals spot behavioural trends and provide improved help and support in this field.

Karen Conway, Clinical Governance Lead at Sedgefield PCT said: “Sentinel has proven to be invaluable in helping us change the culture within the PCT, to acknowledge any mistakes, learn from them and take action to put things right.  Comprehensive use of Sentinel also ensures we can meet NHS legislative requirements.

“With its ease of use and remote access, Sentinel meets our current needs. With PCT reconfiguration pending, Sentinel would be flexible enough to support the needs of a new organisation.“