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CANDOUR - Issue 15 - April 2001

The newsletter of the Joint ASA/JRCALC Clinical Effectiveness Committee and the ASA National Clinical Effectiveness Programme

In this Issue:

Issue 14 CANDOUR INDEX Issue 16

Clinical Risk - learning the lessons

Clinical risk is one of the key components of clinical governance and its management is something that should be part of both the organisation's and the individual's day-to-day practice. Learning the lessons from 'near misses', critical/ adverse incidences and clinical audit are an integral part of continuing education and clinical quality improvement for all staff from the frontline to the boardroom. It is a process that protects both the practitioner and the patient enabling standards of practice to continue to improve.

Prior to Ambex 2000 Dr Judith Fisher (Medical Director of Essex Ambulance Service NHS Trust and a member of JRCALC) conducted a survey of all UK ambulance services to ascertain their progress towards implementing systems for clinical governance. The survey highlighted the need for some central guidance on clinical risk management within the ambulance service.

The reasons for this were two fold:

  1. to provide reference material for use by all ambulance services
  2. to reduce variation in reporting methods across the UK

Dr Fisher presented the findings of her survey to the September 2000 meeting of the Joint ASA/JRCALC Clinical Effectiveness Committee where a sub-group was established with the overall objective to look at the key issues of clinical risk and co-ordinate the production of guidance for all UK ambulance services.

An initial meeting was held to identify the key issues where guidance was required and to identify potential resources and references to inform such guidance. Together these will be worked up into a reference pack to be distributed to all ambulance service.

Following lengthy discussions the key issues were categorised under these five headings to form the main body of the reference pack:

ASA Reference Pack for Clinical Risk

  1. Existing and new CNST standards
  2. Staff information leaflet
  3. Standard incident reporting form
  4. Sharing best practice
  5. Education

There will two common themes, which will run throughout the reference pack, namely -

  • Appropriate and timely reporting
  • Establishing a 'blame free' and supportive culture

A. CNST Standards
The existing standards will be 'ambulance-ised' to show how they are appropriate to ambulance services and their staff. There are already several explicit standards for ambulance services and it is known that more will soon follow. The CNST will be asked to participate in the work of the clinical risk sub-group to ensure future standards are explicit and appropriate.

B. Staff Information Leaflet
Several ambulance services including Essex and West Midlands have produced an information leaflet to raise staff awareness of the issues surrounding clinical risk and its role in clinical governance. A generic leaflet will be produced and distributed to all staff following consultation with ambulance services through their risk managers to determine the appropriate contents.

C. Standard incident reporting form
Although the NHS have produced a report form for adverse incidents it was felt it may not be ideally appropriate for use in the ambulance service. The sub-group will make contact with NHS as part of the 'Organisation with a memory' initiative for national critical incident reporting to develop a national ambulance service reporting tool. Example report forms will be included in the reference pack along with the disclaimer for promoting a 'blame free' culture.

D. Sharing best practice
Ambulance services have a responsibility to share the lessons learned from adverse incidents and complaints in order to improve the quality of care provided nationally. This can be done anonymously to ensure that lessons are learned nationally and are not just restricted to a local level. Several services produce newsletters outlining the lessons learned locally from adverse incidents and the Risk Managers Forum will be approached to assist in how to share best practice and lessons learned in a formalised manner.

E. Education
Education of all staff at all levels is seen an essential in addressing the two key issues of improving the reporting of risks and adverse events, and in establishing a 'blame free' culture. The CPSM will be approached to discuss issues surrounding the role of the 'professional' in risk management and incident reporting, and the role of case review in education to improve practice. Similarly, the NHS Clinical Governance Support Team will also be approached to assist in the education process.

Education needs to be pitched at the level where changes in practice or management are most needed to fulfil the aim of a 'blame free' culture. It is also recognised that the risks to a patient from an ambulance service are part of a wider 'chain of risk' through other sections of the NHS. Communication at handover is an area where specific guidance will be provided given that this is a point where the greatest risks are presented.

If we do not share the valuable lessons we learn every day in our practice we can not improve the service we provide either as an individual practitioner, an organisation or as an ambulance service as a whole. The reference pack currently being pieced together will show how clinical risk management must be part of day-to-day practice for all staff at all levels.

Below are some of the references that will be included in the guidance:

Controls Assurance - NHSE (includes NHSLA information and CNST standards)

Clinical Governance Support Team - NHS

Clinical Governance Bulletin - Royal Society of Medicine

Significant Event Audit - University of Exeter

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17 MAY 2001
11:00 hours - 16:00 hours

The event will be chaired by Neil Mckay, Chief Operating Officer of the Department of Health and Chair of the Corporate Governance Group and speakers will include - the Minister of State for Health, John Denham MP *** the Permanent Secretary/Chief Executive of the Department of Health, Nigel Crisp *** the Director of Clinical Governance, Professor Aidan Halligan *** the Vice Chancellor of Keele University, Janet Finch *** the Director of the Controls Assurance Support Unit, Professor Ellie Scrivens *** the Head of Controls Assurance, Stuart Emslie ********** additional speakers to be announced.

This event will be charged in the sum 99+VAT for NHS delegates and 199+VAT for delegates from other sectors. Any surplus from the funds will be refunded to delegates in the form of training credits for the 2001/2002 training programme.

A limited number of exhibition stand spaces will be available for a charge of 500. Interested organisations, please email [email protected] or fax +44 870 136 0745

On-line booking is available via the Controls Assurance Support Unit site (www.CASU.org.uk) - this is for www users only. NHSweb users should email [email protected] or fax on our dedicated conference fax number +44 870 136 0745.

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PAT - Paramedic Audit Tool

With the introduction of Competence Based Training and Assessment system to East Anglian Ambulance Service NHS Trust it has become vital that paramedics and technicians gather evidence of their competence. This evidence will form part of the training portfolio and will be assessed against IHCD and local standards. To ease the logistics of maintaining records a computer based application has been developed by John Morgan, a paramedic based at Saxmundham Ambulance Station. This is his story about PAT…

" In November 2000 I attended my Annual Paramedic update. On the agenda was the subject of Registration and the obligation to maintain a Portfolio of skills Usage. What followed was a complicated routine, and it was clear to see that this could be a major headache. Surely there must be an easy way to keep track of all these skill codes, skills, etc etc.

I first looked at designing an Access database, it could do most of what I wanted, but not all. So I decided to write my own program that does everything I want, and just as I want it. As it neared completion I offered it to the East Anglia Ambulance Service NHS Trust - EAAS - who are still evaluating it (at time of submission February 2001).

A major advantage is that the user requires no other program, such as MS Access, which is an expensive piece of software. A lot of people have a PC, but not all have this software, or the patience and knowledge to build a fully fledged data base. Also there is problem that these portfolios require access to confidential information, which really should not be taken away from Trust property.

The Paramedic Audit Tool was completed in December 2000 and released on the web on Christmas day (see link at end).

It has 5 sections, each working in a similar fashion. A screen to view and edit data, one to add data, and one that preview what you are about to add.

The Sections are:

  • Portfolio
  • Cannula
  • Drugs
  • Intubation
  • Resus Audit.

It has a back up facility and few options to turn features on and off.

This release was designed as a preview, an example of what the final could do. There is so little software built for Paramedics it’s shameful. This version was all my own idea, but I wanted feedback for a better version. My plans for the next version are:

  1. Station level, multi version with password protection and the ability for the administrator to oversee and verify the other users.
  2. A complete portfolio program that does everything, holds copies of paperwork etc etc, then when you want a portfolio, you just press the print button.
  3. Both version would be customisable for an individual groups needs as the various Trusts all do different things.

To date there has been over 200 downloads from the site and I have sent out dozens of copies on CD.

There are over 100 registered users.

I will be posting an updated version that fixes a few minor annoyances in the next week or so, these are mainly design issues for people outside EAAS Trust, and I am about to start work on Version 2. "

John Morgan, Paramedic, East Anglia Ambulance Service NHS Trust

PAT - Paramedic Audit Tool can be downloaded for free from the following website, which also lists contact details for John Morgan - http://www.cleversod.clara.net/

Following download you can evaluate PAT for 30 days before registration with John is required.

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An NeLH communications area for the Coronary Heart Disease NSF

and CHD Partnership Programme.

The mission of the National electronic Library for Health (NeLH) is to provide easy access to best current knowledge and know-how. This is particularly important in addressing Coronary Heart Disease where the gap between what we know and what we do could be closed with massive benefit resulting.

The National Service Framework for Coronary Heart Disease has been designed to set out a system of care which will close the gap between what we know and what we do, based on best current evidence. The CHD Taskforce charged with the responsibility for implementing the NSF will lead the programme of change and development which will transform prevention, treatment, rehabilitation and care.

The NeLH Virtual Branch Library For Heart Disease will house the evidence base on which policy and its implementation are based, but users of the NeLH have asked for more information about the work of the Taskforces responsible for NHS modernisation, and to do this we are setting up information zones in which the messages from the Department of Health and the Taskforces will be made quickly and easily available, and linked to the Virtual Branch Library for Heart Disease.

We will work with the CHD Taskforce, the Heart Team and the CHD Partnership on a weekly basis to keep you in touch with the implementation of the National Service Framework.

J A Muir Gray, CBE, DSc, MD, FRCP (Glas&Lond)
Director - National electronic Library for Health

Colin Gordon
Director, NeLH Guidelines project

For more information check out the website at http://www.nelh.nhs.uk/heart/

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The National Electronic Library for Health - Emergency Care branch


The government's Information for Health strategy announced the creation of a National electronic Library for Health (NeLH). The aims of the NeLH are to provide easy access to best current knowledge, to improve health and healthcare, clinical practice and patient choice.

The basic principles underpinning the development of NeLH are that it should be obsessed with the quality of knowledge, be concerned with both knowledge and the skills to manage and apply that knowledge, be equally open to patients and clinicians and that it should create and sustain communities of users.

This branch library for emergency care (NeLH-EC) is now being developed by the Emergency Medicine Research Group (EMeRG) based at the University of Warwick. It will include resources that are of interest and use to all providers of emergency care (e.g. A&E departments, minor injury services, ambulance services) and will be available both on the NHSnet and the Internet. Long term, it may even be available in the cab of the ambulance or via your WAP phone.

NeLH-EC has four main components (the shelves of the library). The Reference shelf provides access to sources of information that are commonly used and useful. This will include electronic textbooks, access to on line services (e.g. Toxbase, UK telephone directory) links to journals and a journal club.

The second shelf will be the Archive shelf. This is a collection of documents such as protocols, training packages, major incident plans, patient information leaflets. Anyone can donate these to the library, so that others can adopt them or modify them for local use. It is hoped that this resource could save us all a lot of time in writing our department handbooks and similar projects. If you have documents that could be placed in the Archivee shelf, please let us know.

The third shelf is the Guidelines shelf. The evidence based clinical guidelines will give three levels of knowledge:

  • Quick read guidelines
  • Full guidelines with background information
  • Access to latest research information, including literature searching capability.

This should allow any healthcare professional to look up the latest treatment at his desk or workstation. These guidelines will have a standard structure and will all have been peer reviewed. This is without doubt the most ambitious part of the project and is therefore likely to be the last component to be completed.

The fourth shelf is the Learning shelf. This is for when you are sitting at the PC during a rare quiet spell. One of the elements of this shelf will be an interactive learning zone e.g. trauma moulages, resuscitation scenarios. The idea of this shelf is to have fun whilst learning.

As the project is only just commencing an important component of the project is consultation with all potential users. This site is based on the team's initial ideas which will no doubt change with time. We would value any suggestions on future developments. Please let us know what items you would like included, what links you want installed and what help you can offer the team by clicking on the 'Feedback' button and filling in the form, or contact the team at the address below.

Further information:
NeLH - http://www.nelh.nhs.uk
Virtual Branch Libraries - http://www.nelh.nhs.uk/vbls.asp
NELH- Primary Care - http://www.nelh.nhs.uk/vbranchlibs/primary .asp
EMeRG - http://www.emerg-uk.com

NELH-EC Project Team, c/o Emergency Medicine Research Group, Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL.
Email: [email protected]

Project Team:
Matthew Cooke, University of Warwick (Project Director)
Kath Charters, Welsh Ambulance Service
Rob Crouch, Southampton University
Jeremy Harrison, Warwick Hospital
Joanne Higgins, University of Warwick
Stewart McMorran, Northampton Hospital
Justin Nicholas, Southampton General Hospital
Malcolm Woollard, Welsh Ambulance Service

An advisory group is being established which includes representatives of BAEM, the Faculty of A&E Medicine, the Faculty of Emergency Nursing and the Ambulance Service Association.

Dr Matthew Cooke
Senior Lecturer in Emergency Care
University of Warwick and Walsgrave Hospitals NHS Trust.


If you have any comments or wish to contribute to CANDOUR please forward any information to:

Stuart Nicholls
Programme Manager
Ambulance Service Association
National Clinical Effectiveness Programme
c/o Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone, Kent ME17 4BG
Email: [email protected].org.uk Tel/Fax: 01622 664929

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