1233 Stop the line initiative in hull neonatal unit (reporting and learning from near misses)

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<h3>Aims</h3> The intention is that any staff member, irrespective of role, grade, seniority, or experience, can call ‘Stop the Line’ if they see that required safety procedures and checks are not being followed. ‘Stop the Line’ is a well-known control mechanism with the primary aim of promoting patient safety. All members of staff are encouraged to ‘Stop the Line’ if they notice a series of steps/process that could potentially cause harm to a patient. The event/incident that is stopped is referred to as a ‘near miss’. ‘Stop the Line’ initiative piloted in HUTH in certain clinical areas and was intended to be used any point in an operating theatre, interventional procedure room or any clinical or other environment when increased patient focus and concentration is required. Patient safety experts argue that the root causes of near misses and adverse events are similar.^1,2 Therefore, detecting root causes of near misses can help us to correct these causes and prevent future adverse events. The goal of a reporting system is to identify and remove the root causes of incidents (not merely counting the events) and this can be achieved by near misses.¹ <h3>Methods</h3> This initiative rolled out to the Neonatal unit in Hull teaching hospital Mid November 2021. Posters were developed to educate staff on what near misses were and promoting ‘Stop the Line’ reporting through either the DATIX system or paper reporting forms (see figure 1). Near misses reported were shared as lessons with staff without guilt and blame culture that may be associated with other types of incidents. -Initiative introduced to senior nursing staff in Band 6 meeting and to nursing educator lead and information distributed to remaining nursing staff. -Initiative presented to NICU consultant business meeting and on grand round where all medical team made aware about it and how to report near misses and what a near miss event is. <h3>Results</h3> This is currently work in Progress: -Five near misses reported since start of pilot period for this project. -Four of them related to medications and prescriptions. -All learning lesson shared with team and reporters praised for been patient safety advocate. -Pharmacy team involved in the initiative for future reporting and lessons sharing after theme of medication identified as common near miss area. -Ongoing Staff education and encouragement to report near misses and lessons sharing. <h3>Conclusion</h3> Reporting near misses is one of the practical solutions to the perplexing problem of patient safety. Evidence suggests that the culture of patient safety and the characteristics of errors may have a significant impact on reporting. <h3>References</h3> Aspden P. <i>Patient safety: achieving a new standard for care</i>. 2004. Institute of Medicine; USA. [Google Scholar]. Lamb BW, Nagpal K. Importance of near misses. <i>BMJ</i>, 2009;339(3):b3032. [PubMed]