What is DATIX?

Datix is a Risk Management Information System designed to collect and manage data on adverse events (as well as data on complaints, claims and risk).

The purpose of collecting such data is to identify learning and implement improvement. The ultimate goal is to make healthcare safer for NHS patients and staff through shared learning and continuous systems improvement. Hence, Datix is essentially a quality improvement tool.

It is crucial that staff feel empowered and are motivated to report events through Datix to achieve these aims. For this reason, there should not be a blame culture around Datix and submissions should not be used to “target” an individual. Language such as “I’m going to Datix you” is not conducive to the aims of the process and certainly does not promote a culture of psychological safety for the team

What happens when I complete a Datix?

Members of the management team (such as departmental managers, the clinical director or other senior clinicians) will be able to review a Datix entry that has been submitted which is relevant to their area. They have responsibility to assess if any immediate action is needed to ensure patient safety, and then to either review the Adverse Event themselves or ensure it is allocated to an appropriate person for review. They may add staff from other areas to review the Datix if deemed appropriate. The category of Datix may also affect who can review it, eg. for a Medication event, pharmacy staff may need access.

No adverse effect/Minor harm

Review by a local manager who undertakes further inquiries/questions and ascertains any necessary improvements or learning. Once these are implemented the event can be closed.

Moderate harm

Escalation to Senior Staff (eg. Clinical Nurse Manager) but local review can still be undertaken if appropriate. Once learning and improvements have been implemented the event can be closed.

Major harm or death

Escalated to Senior Management who will establish a review team and follow the Significant Adverse Event process

The timescale for closing the event also depends on the level of harm reported:

No adverse effect Approved and closed within 10 working days of being reported

Minor harm Commence local review within 10 days and close within 4-6 weeks

Moderate harm Commence local review within 10 days and close within 4-6 weeks

Major harm/death Commence review within 10 days and close within 3 months

Once a Datix review is complete, the person who submitted the Datix will receive feedback on the review by default as long as they have provided a valid NHS email address on the form. The reporting person can opt out of receiving feedback if they choose. In some rare circumstances, if it is deemed not appropriate to provide feedback to the reporter, then this may not be sent.

Feedback will usually include the Summary of Review and Lessons Learned fields from the review. This is important to contribute to wider learning from the event and managers may also consider whether the learning should be communicated more widely.

In addition, the NHS Lothian Medical Education team aim to provide further opportunities for learning and support by emailing the Named Educational Supervisor for any doctor in training (DiT) who submits a Datix. This email will come from MEDLearningFromDatixes@nhslothian.scot.nhs.uk and will not include details of the Datix. This email is to prompt Educational Supervisors to offer a meeting with the DiT to discuss the event for supportive purposes only. A meeting is not mandatory although could provide an opportunity for reflection and professional development.

Some definitions

Adverse event: an event that could have caused, or did result in, harm.

Near Miss: any adverse event which could have caused harm.

Significant adverse event: an adverse event which has led to major harm or death.

Never Event: an event which should never happen due to the availability of nationally agreed procedures, protocols or guidelines.

Minor harm: for example, a patient required additional or prolonged monitoring after an event, or minor treatment

Moderate harm: short term harm requiring additional treatment or procedures.

Severe harm: permanent or long-term harm to the patient

Useful resources to learn more about the Datix process

Learnpro modules on Datix:

• Lothian: Datix -Guide to Adverse Event Management (Manager perspective)

• Adverse Event Management page (including link to Datix)

• Quality Improvement Support team page including links to Risk Grading Matrix via Risk Register subpage

• Adverse event grading table (similar to Risk Grading Matrix and accessible by using intranet search)

• Adverse event review tools matrix (accessible by using intranet search)

Intranet resources:

Wikipedia page on the history of Datix: https://en.wikipedia.org/wiki/Datix