Patient safety
Information technology (IT) IT systems can improve patient care by removing transcription errors, linking records and storing information on patient histories among many other functions. However, these improvements are only realised when the systems are used as intended and workarounds are not employed. IT systems should be fit for purpose, they are reliant on correct setup, sufficient staff training, and ongoing system development. Staff should receive proper training when IT systems are used and maintain competence in downtime procedures when IT is not available. Furthermore, where IT is used as a safety
measure, this should not replace staff knowledge and should be there as an additional barrier. Many errors included overriding alerts, overreliance on alerts to ‘stop’ errors, alerts not updated, and issues around legacy data. Healthcare staff must understand ‘why’ as well as ‘how’ a particular procedure is required. Alongside the 2022 Annual SHOT Report, the
SHOT Collaborative Reviewing and reforming IT Processes in Transfusion (SCRIPT) launched the document ‘Using Information Technology for Safe Transfusion’ to detail how IT systems can be employed throughout the transfusion process, help when investigating transfusion incidents and when writing business cases for transfusion IT. 6
Acknowledging continuing excellence (ACE) In 2022, a total of eight reports were received under the ACE category and showed a wide range of themes such as innovation, communication
‘Quick wins’
3 Consistent positive feedback to staff within day-to-day com- 3 munication style and debriefs
Reporting to SHOT ACE Medium term departmental actions
3 Sharing of positive events as well as incidents at departmen- 3 tal meetings
Using change request tools to record excellent innovations or solutions to problems, allowing these to be incorporated 3 into future document versions
Allocation of time for ACE or improvement projects within 3 job descriptions and capacity planning
Audit and audit tools such as the NCA vein-to-vein 3 (see ‘Recommended resources’)
Longer term goals
3 Presentations to RTC or other regional network meetings 3 Submitting abstracts to national meetings 3 Submitting research papers 3 Sharing resources
Fig 5. Acknowledging Continuing Excellence (ACE).
and collaboration, and patient focus. Learning from excellence provides the opportunity to celebrate the hard work of healthcare staff and improves safety outcomes for patients. These should be shared widely to enable other departments and organisations to benefit. There is also great benefit to learning from
everyday work, as this is less resource intensive, does not require the presence of adverse events
Extracting the learning from ACE reports to enhance safety 3 Raising positive ‘compliments’ or reports of excellent practice
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