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3.3.1 PRIORITY 1 – Further Embed
a Safety Culture throughout the
Organisation

The Trust identified a specific priority to maintain our
strong and growing safety culture by putting specific
attention into prompt recognition and treatment of
deteriorating patients, including implementation of the
sepsis pathway and into reducing hospital acquired
infections. A high level of incident reporting to the
National Reporting and Learning System (NRLS) is also
recognised as an indicator of a high safety culture

In striving to deliver this priority, the Trust agreed to
place a specific focus on:

• Remain in top quartile of number of incidents
reported through NRLS compared with peer trusts
• Prompt recognition and treatment of deteriorating
patients including implementation of the sepsis
pathway
• Reducing hospital acquired infections

Remain in top quartile of number of incidents
reported through NRLS compared with peer trusts
Improvements

• Weekly meeting of harm assurance action log,
Aim: To maintain a high level of incident reporting in demonstrating assurance of patient safety
a culture of openness and willingness to learn improvements.
• Governance and Quality assurance intranet site
Targets:
now available for all staff which includes, national
1. Remain in the top quartile of number of incidents and local guidance on management of incidents
reported compared with acute specialist trusts. including serious incidents, sharing lessons learned
from incidents, investigation reports and action for
Outcomes - 2017/18: improvement, safety notices etc.
1. Alder Hey is the third highest reporter of incidents • Development of ‘Step by step guides’ for the
maintaining its position in the top quartile. management of incidents via the electronic risk
2. Further increase in reported incidents in 2017/18. management system.
Data source: NRLS website – March 2018 • Safety alerts shared Trust wide to ensure learning and
minimise patient safety risks.
• Lessons learned bulletins shared with all staff
promoting learning and continuous improvements in
A high degree of focus has been placed on incident patient safety.
reporting within the Trust, with a higher reporting of • Human factors training in theatres.
incidents, particularly no harm and near miss incidents,
being indicative of a strong safety culture, with a • Maintained mechanisms of feeding back reports
willingness to be open and learn from mistakes. to staff, for example see ‘theatre monthly incident’
The latest report from National Reporting and Learning summary sheet (overleaf).
System (NRLS) shows that for the period 1st April
2017 to 30th September 2017, Alder Hey was the third Future Plans
highest reporter of incidents amongst its peer group of • Multidisciplinary half day ‘lessons learned’ events
acute specialist trusts. We are also the highest reporter
of incidents amongst all paediatric trusts. • Combined RCA and Human Factors training
• E-learning incident management training package

Alder Hey Children’s NHS Foundation Trust 105 Annual Report & Accounts 2017/18