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.
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.
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.
Back to the top