Background Patient safety is the avoidance of unintended or unexpected harm to people during the provision of health care (NHS England. The NHS patient safety strategy: safer culture, safer systems, safer patients 2019). Reporting incidents allows staff to learn from mistakes and change practice where needed (NHS England. Learning from patient safety events. [Internet]).

Aims To identify an effective way in externally sharing any serious safety issues identified by patients admitted to the hospice from community or healthcare environment. This includes any CQC reportable incident, safeguarding concerns, extensive pressure damage and medication incidents (Care Quality Commission. Regulation 18: Notification of other incidents. [internet] 2023). Our aim is to provide feedback, identify poor practice and enable learning in a more thorough, robust way.

Methods A working group was formed at the hospice consisting of, Inpatient Unit and Community leads, Pharmacy, and Administration. Incidents are reported via our hospice reporting system and serious clinical incidents result in an investigation. We have a monthly clinical incident meeting where all incidents are discussed and learning points are identified to be shared. Any item to be escalated is discussed with an action plan in place.

The Patient Safety Incident Response Framework (PSIRF) (NHS England. Patient Safety Incident Response Framework. [internet] 2022) recommends an emphasis on involving those who are involved in incidents to understand their experience and so initially we liaised with Community and Acute Hospital patient safety leads to identify what our intentions were and establish engagement. A ‘Learning from Incidents’ form was developed, reviewed, agreed and shared and is currently in use for escalating any significant incidents externally.

Results Following positive feedback and discussion with another local hospice, we have shared our escalation algorithm and ‘Learning from Incidents’ form with them in order for the tool to be used city-wide.

Conclusion As PSIRF is becoming more familiar and emphasis is on learning and improving practice after an incident has occurred, the ‘Learning from Incidents’ process complements this, ensuring appropriate escalation to those involved.