Datix reporting in University Hospitals of North Midlands: what can trainees learn from this?

Introduction

Datix is a web-based incident reporting and risk management software used in many hospitals in the UK to report incidents. The purpose of reporting an incident is to alert the healthcare system to risks and to provide guidance on preventing potential incidents that may lead to avoidable harm or death.¹ Datix can be used to report any adverse incident that has the potential to produce unexpected or unwanted effects, or any incident which has a consequence or a learning point. An event that causes a loss, injury or a near miss to a patient, staff or others.²

Materials and methods

• The primary objective was to analyse the common themes and modifiable risk factors within Datix reporting in University Hospitals of North Midlands NHS Trust and determine whether there are more effective ways for trainees to learn from their errors.

• The secondary objective was to gather managerial responses to these Datix incident reports (‘datixes’) in order to gain a perspective on how the trust is working to resolve some of these common complaints.

• All datixes were from the acute medical unit and emergency departments at County Hospital, Stafford received by one consultant.

• 93 datixes were selected in total, of which 22 were duplicates and 15 could not be viewed due to problems with access. These have been deleted from the dataset analysis and hence a total of 56 reports were analysed.

• We tabulated each datix in Microsoft Excel (2010), identified what the incident was, identified the nature of the incident, harm caused (if any) and how the incident was resolved.

Results and discussion

• In the majority of cases no harm was caused, as the incident was flagged before any adverse consequences of the incident could take place. The two drugs that were commonly incorrectly prescribed were insulin and low-molecular-weight heparin.

• Datix is an inefficient process and it takes much-needed resources to review these cases, which often do not amount to significant change in practice when it could be used as a training opportunity for junior doctors (in the form of reflection) who are often at the receiving end of these datix incidents.

• Managerial responses to these errors were seldom required (Table 1), as most of the time the error had been corrected prior to the datix being completed, resulting in no patient harm.

• Electronic prescribing was often cited as a way of reducing the number of incidents of duplicate prescribing.

• The most common reason for an incident being filed was prescribing errors (Fig 1), often due to lack of knowledge regarding the medication, for example with insulin treatment pathways. Secondly, the emergency department prescription chart not being integrated with the medical team's prescription chart.

Table 1.

Managerial responses to datix

Managerial responses	Frequency
No action	46
Reflection	2
Disciplinary action	0
No response	8

Fig 1.

Reasons for datix.

Conclusion

Reflection could be more beneficial for the trainee from an educational point of view as well as from a development perspective, as it addresses the error made and the reflection helps the individual learn from the incident.³ Also, ultimately there is good evidence to suggest that electronic prescribing can help to cut down a significant proportion of these basic errors.⁴