All these changes took at least a year to
develop and apply and the new system has
been in place fully for just under a year. A
recent re-audit is encouraging:
» The mean time delay between X-rays
being requested and taking place was
reduced to two hours 10 minutes – just
over half the average in the initial audit;
» Documented misinterpretation of
check imaging was found in only one
case;
» Poor or no documentation in clinical
notes was reduced to 26% of audited
cases – a significant improvement;
» Nearly 80% of requests for check
imaging were handled by the radiology
department within normal working
hours, and there was a significant
increase in the number of tubes being
adjusted under X-ray guidance in the
department by experienced and trained
radiographers, rather than on the
wards.
Changing the culture to one that promotes
safety in a large organisation such
as an NHS trust is inevitably difficult. Specific
challenges for us were: ensuring that
staff involved felt they had a stake in the
project; ensuring senior staff engaged with
all levels of health professionals in the
trust; and standardising practices across
the two very different hospital sites.
By making sure the team included
members from different specialties in the
trust, as well as a mix of senior and junior
members, everyone felt involved and their
voice was heard. Where there were differences
of opinion, the whole team decided
on the path to follow, avoiding the problem
of health professionals feeling the project
was too top-down or being forced on them.
Likewise, initially tackling the multiple
differing causes of the underlying problem
head-on and simultaneously seemed
daunting, but ensured that systems were
changed rapidly and effectively.
When patient safety is at stake, politics
and inefficiency cannot be allowed to
interfere with the changes needed to
address them, and tackling the root cause
and all of the contributory factors proved
to be the best way to achieve this.