Mr Learning Event – for recording learning points from our “mortality & new cancer diagnoses review meeting”

Practice Leads

  • Doctors: Ramesh Mehay & Pardip Sandhu
  • Nurse: Zoe Booth
  • Admin: Pam Brown

Date Reviewed

11th August 2016

Date of Next Review

September 2017

It is important to review the medical records of our new cancer diagnoses and of patients that have recently died in case there is something we can learn from them to help us with our patients in the future.  Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of planning) or a deviation drom the process of care that may or may not cause harm to the patient.   Patient harm can occur at the individual or system level. And medical errors can contribute up to a third of all deaths.

Learning points can be for the individual or for the organisation as a whole.   In discussing new cancer diagnoses or deaths, we are not trying to apportion blame but instead help individuals and the organisation learn and thus continue to professionally develop.   Such discussions may help to prevent further errors on an individual and system level thus protecting other patients.

Ashcroft Surgery is an organisation which pays high regard to its educational and learning environment because we know it is that which enhances patient safety.

The main question we are trying to answer for NEW CANCER DIAGNOSES

  1. Could the cancer have been picked up sooner?
    • For instance, was there repeated visits to the Health Professional about a suggestive symptom?
    • Was there a delay in referral?
    • Look at both system and individual failures.

The main questions we are trying to answer for a review of RECENT deaths

  1. If the death was unexpected, was there anything preventable in the process of medical care that contributed to the death? 
    • This doesn't just mean on an individual personal level but also in terms of whether there were system failures in our organisation or in that of an external one.
  2. If the death was expected, did the patient have a good death?
    • A good death is one in which the patient was pain-free, comfortable, had their wishes carried out and died where they wanted to.
  3. In all cases: what support is in place for the family?
    • Make contact if you don't know.

Learning through Mr Learning Event

  • There will be mortality and new cancer review PLT meetings at Ashcroft surgery on a 3 monthly basis.
  • Two lists will be developed by Pam Brown before the meeting.
    1. a list of patients with new cancers
    2. a list of patients who have recently died
  • The whole team will go through each patient in turn in a group setting.   The group will be multidisciplinary.  Thoughts will be shared by people who knew of the patient and an attempt made to answer the questions above.
  • A summary of the discussion will be recorded in SystmOne's Mr Learning Event during the meeting.
  • Notes will be kept short where there is nothing much to action.
  • Where there are significant learning points, these will not only be recorded in Mr Learning Event but also shared via an email to our health professionals to help disseminate the learning (whilst trying to maintain patient confidentiality).