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Thread: Incident investigations- resulting in staff disciplinary/ blame

  1. #1
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    Incident investigations- resulting in staff disciplinary/ blame

    Reports have recently been received that seem to indicate that some BMS staff are being taken through formal disciplinary actions and downgrading after lab incidents. If you believe an investigation at your site isn’t being conducted fairly and by looking into all potential factors, please email me: uktlc@outlook.com

    With all transfusion investigations the following must be included as part of the report, particularly if this was a SABRE reportable event:

    • Was there adequate staffing, skill mix, supervision, advisory support and guidance at the time of the incident as per BSQR & UKTLC Standards?
    • Did the member of staff involved have the right competencies, knowledge and training?
    • Are the right SOPs in place to describe concessions during emergencies?
    • If part of the Corrective Actions is to formally discipline staff then this should also be stated in the SABRE report.

    For colleagues concerned about this being perceived as “whistle-blowing”, I would say that we all have a duty of care to both our patients and staff and need to stand up to any unacceptable practices- it isn’t easy but you have the support of all the UKTLC organisations. We can’t let this culture undermine the improvements we are trying to make.

    You also have Mike Dawe available to contact:
    E Mail: Michael.Dawe@mhra.gov.uk Tel: 0203 0806239

    Thank you.

    Rashmi Rook,
    Chair, UK Transfusion Laboratory Collaborative.
    Last edited by Rashmi; 21st Jul 2018 at 12:35 AM.

  2. #2
    From a SABRE reporting point of view, to be clear, staff disciplinary matters are not covered by the BSQR and therefore not included within the MHRA’s remit. However, in my experience disciplining staff for their error does not always address the root cause and may often overlook fundamental problems within the QMS and may not prevent the possibility of that error reoccurring even if disciplinary action is deemed appropriate.

    The recent SHOT symposium had a number of talks which addressed human factors and errors and echoed the message MHRA have been discussing in recent SHOT chapters.

    https://www.shotuk.org/events-2/meeting-presentations/

    Walking the tightrope – maintaining confidence in the face of errors – Trevor Dale

    Oops I did it again – Carol Cantwell

    Both the above presentations pointed to improving the quality system to improve safety and two presentations from Susan Robinson and Marie Scully (unfortunately presentations not posted) demonstrated how to effectively investigate errors and make those improvements to the system in practice. The presentation from Susan especially demonstrated how up to 28 improvements in the transfusion quality system in both the lab and clinical areas can improve safety. That was achieved by including the staff responsible for the errors in the investigation and being part of the improvement process.

    Human behaviour is determined by human factors. Human factors can be related to the individual, the task and the environment/organisation. To affect the outcome of human behaviour to ensure a safe, consistent outcome you need to improve organisational culture, the environment in which we work, design processes that achieve the correct outcome, write informative SOPs, train people and assess their competency properly, supervise them effectively, identify and eliminate distractions or minimise the effect of distractions and ensure there is an adequate capacity and business continuity plan to meet your business processes.

    The QMS process MUST ENCOURAGE incident reporting, and not discourage it through fear of disciplinary action.

  3. #3
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    An open culture of reporting is essential with a full root cause analysis being carried out being the key action. Unfortunately training in root cause analysis is rare. i did it as part of a management certificate and diploma and lucky enough to have have just been offered it through work. Maybe this is something we could bee looking at offering through our TAG groups or RTC’s (clinically they need this as much if not more than the labs do) to help managers when these situaiions arise. Staff do need to be looked at but properly as part of the process and not as the only line of investigation.

  4. #4
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    Hi Chris ,
    Disciplinary matters may not be in the remit of the MHRA, but there is probably a causal link -with encouraging high reporting of events ( part of continuous improvement) to people who don’t understand RCA/ Human Factors and the correct way to carry out investigations- it may just be misinterpretation of the regs, ignorance, or fear of the MHRA that is causing sites to take these actions. “The MHRA would expect us to do this!!! ...” or "the inspector looked at me during the inspection as if to say you need to investigate this staff member!!!"
    Things to consider.

    Also, culture is the main issue- how many times do I hear colleagues refer to staff as “culprits” when an error (usually very minor) is made, they need to be referred to probably as the victim of a poor system. This lack of respect for dedicated and hardworking people ( lab, nurses, porters, etc) who have other pressures in their roles is unacceptable and has to change!

    Anna, good idea about the training- could be a short session at the TADG/ TP meetings on reviewing some cases?

    As mentioned many times:
    We all come to work intending to do a good job and it is mainly faulty systems and processes that let us down. Fix the systems.
    Last edited by Rashmi; 31st Jul 2018 at 12:07 AM.

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