Sign Up

Developing person-centred analysis of harm in a paediatric hospital: A quality improvement report (UK)

Case Study

posted by WM Admin on 31 March 2015

Awareness of what happens in real time is one of the ways to develop a safe system within a culture of safety. At Great Ormond Street Hospital, the authors developed and tested a tool specifically designed for patients and families to report harm, with the aim of raising awareness and opportunities for staff to continually improve and provide safe care.

Over a 10-month period, they developed processes to report harm, and used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. They measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool analysed in real time. An independent person working with the families was best placed to support reporting.

Immediate feedback to families was managed by senior staff, and provided the opportunity for clarification, transparency and apologies. Feedback to staff provided learning opportunities.

Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is essential to achieve safety. The high number of newly identified ‘near-misses’ and ‘critical incidents’ by families demonstrated an underestimation of potentially harmful events. This testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised situation awareness. The authors believe that this will lead to improved and safer care in the longer term.

This is an open access report and can be read in free full text at:

Lachman, P., et al. (2015). Developing person-centred analysis of harm in a paediatric hospital: A quality improvement report. BMJ Quality & Safety, 24:337-344