W10 Mind the Gap

Background We undertook a qualitative analysis of the effectiveness of the dissemination of learning points from clinically significant incidents within our Emergency Department. We found learning was poorly disseminated and adverse incidents were not reduced. Reflection of the standard investigative process through observational study revealed a significant gap between work as imagined and work as done. Focus group discussions revealed a lack of awareness of recent serious incident recommendations amongst the wider ED team. We developed an innovative framework utilising process mapping, simulation and social networks to investigate and learn from adverse incidents. The simulation was utilised to engage key stakeholders to visualise real work environments, recognise defects in the system and empower them to create and implement the solutions in a safe learning environment. Key messages post simulation were conveyed using enterprise social networks. Intended learning outcomes Explain current challenges within adverse incident investigations through case history New framework to analysis adverse incidents using process mapping and simulation Innovative approaches to dissemination of learning through enterprise social networks Structure of workshop Pre workshop – flip the classroom approach. Sample SEA sent to participants prior to workshop. Participants asked to reflect on sample with the positives and challenges of SEA report. 10 minute interactive presentation on ergonomic principles and collation of information 30 minute facilitated exercise utilising the new approach to investigation and creating a timeline. 10 minute interactive video reviewing the simulation process to facilitate identification of latent errors, engagement of key stakeholders whilst creating a safe learning environment. 10 minute facilitated discussion on new methods to disseminate learning. 10 minutes review of workshop and questions from participants. References Shorrock, S. The varieties of human work, Safety Differently, http://www.safetydifferently.com/the-varieties-of-human-work/ Pucher P, Tamblyn R, Boorman D, Dixon-Woods M, Donaldson L, Draycott T, Forster A, Nadkami V, Power C, Sevdalis N & Aggarwal R. Simulation research to enhance patient safety and outcomes recommendations of the Simnovate patient safety domain group. BMJ Sel 2017; 3 (Suppl); S3-S7