G227(P) Learning from Both Adverse Incidents and Excellence in the Neonatal Intensive Care Unit

Abstract

Aims To address the challenges of effectively disseminating learning outcomes from neonatal significant clinical incidents (SCIs), while avoiding possible detrimental effects on staff morale. Methods It was recognised that learning outcomes from neonatal SCIs were not consistently communicated to those providing care to babies day to day. We proposed developing feedback bulletins to convey these learning points to neonatal staff. It was however appreciated that a focus on adverse clinical outcomes could have a potential detrimental effect on staff morale. The concept of ‘Learning from Excellence’ is becoming more recognised in healthcare, providing new opportunities for learning and improving staff morale and resilience. Therefore, to complement the SCI bulletins a series of Learning from Excellence bulletins were also designed, highlighting good neonatal care across the health board and associated learning points. These bulletins were communicated electronically to all neonatal medical and nursing staff as well as displayed on a dedicated neonatal governance board. Results ‘Lessons Learned’ incident feedback bulletins and ‘Learning from Excellence’ bulletins were developed each time learning points emerged from SCI reports or from good neonatal practice. To date six incident feedback bulletins and three Learning from Excellence bulletins have been produced and disseminated. A survey of neonatal trainees found that 100% of respondents found the bulletins to be very helpful (on a scale of 1–5 with 1=very unhelpful, 5=very helpful) and likely to improve clinical practice. All respondents felt the bulletins had a positive or neutral effect on staff morale. Conclusions Succinct electronic feedback bulletins are a good way of highlighting important learning outcomes from neonatal SCIs. Combining these with learning bulletins from good clinical practice may help to convey learning points while improving staff morale.