Background
SPHERE is a non-commercial, NHS System designed to allow the simple acquisition of significant and critical event reports – and the subsequent sharing of any learning points gained from the investigation and resolution of these events.
SPHERE was designed and implemented by Dr Chris Moultrie (EM CT3) and Mr Scott Hepburn (EM Consultant), with support from NHS Scotland and the Emergency Medical Retrieval Service (EMRS).
The system was designed in response to the perceived difficulties and complexity in applying the NHS DATIX system to the wide variety of services, situations and clinical demands of the pre-hospital, emergency and retrieval environments. Therefore, we examined the processes used by the aviation industry and by NASA – both considered Gold-Standards in the field of safety systems – to design, from the ground-up, a simplified, confidential and effective significant and critical event reporting system for the pre-hospital, emergency and retrieval community.
Further information can be found in our SPHERE Information Poster
Submitting to SPHERE
Online reports submitted to SPHERE are immediately entered into an NHS server hosted secure database. The data is confidential (not anonymous) for the submitter to allow us, or their own organisation, to contact them if further information is required. No patient identifiable data is stored within the SPHERE database.
Once a report has been submitted, it is stored for reference on the SPHERE database and is also returned to the submitting service’s clinical governance / risk management lead to allow further action, follow-up and resolution to take place at the local level. SPHERE is intended as simply a conduit and resource pool for this process and we have no intention of taking the process of event review and resolution away from individual teams.
When a team has completed their follow-up and implemented any actions resulting from the event report, a second submission to SPHERE is made, illustrating the outcome, learning points and any recommendations which that service would like to make to others.
The original report and the follow-up report are then collated, the submitter details (individual and service) are removed to now make the data anonymous and the SPHERE Report is considered complete. This anonymized report then remains in the SPHERE Database for future reference and sharing of learning points with other services.
There are currently two submission pathways within SPHERE:
1. Paper-based System: where paper forms are available to download from the SPHERE website and are then submitted internally to your organisation. Information sharing is then performed on a form-by-form basis with only the forms which you want to share being sent to SPHERE for collaborative reporting. We recommend this system for teams who are new to the concepts of event reporting or do not have a well developed clinical governance structure to allow the introduction of significant event reporting without the added complexity of online event reporting or automatic collaboration. However, it is expected that services initially joining via this pathway will proceed to electronic reporting and the associated information sharing principles.
2. Electronic System: a submission is made electronically via your service’s portal on the SPHERE website. This report then goes through the full SPHERE process as outlined in the “Submitting to SPHERE” section above – including the retention of the report for future reference or sharing requests. This system is recommended for services who already have an internal significant event reporting system or developed clinical governance structure who wish to make the step to collaborative event reporting or information sharing and thereby gain the benefit of access to multiple services reports, a wide pool of experiences and varied problem-solving capabilities.
Further information regarding this process can be found in the Process overview document.
Information Sharing
All reports which are submitted to SPHERE have statistical data extracted from them to allow monitoring of significant event rates, severity and domain. The statistical data is completely anonymized from the beginning and no service or submitter data is included. To help create a more transparent system for significant event reporting, this anonymized, statistics only data (there will be no reference to specific events or narrative data from submitted reports) will be published in the public domain.
Currently, completed, anonymized reports will be stored securely within the SPHERE database and will be available to services for specific collaborative Clinical Governance meetings or conferences. Services will always have unrestricted access to their own reports. It is hoped, however, that in the future it will be possible to make all the completed reports available for services actively involved in the SPHERE system to access freely for their own learning.
We also aim to produce the SPHERE bulletin, based on the aviation industy’s “CHIRP” programme newsletter, which will actively distribute information within the SPHERE-engaged teams in our aeromedical community.
Further information can be found in our Completing the Clinical Governance Loop poster.
Joining SPHERE
If your organisation is interested in joining SPHERE and contributing to the UK’s newest significant event reporting system then please contact us.
We are actively seeking regional representatives for SPHERE and are delighted to welcome Dr Ed Valentine (EM Consultant) as the SPHERE Representative for England South. If you think you can deliver the SPHERE service to your region and would like to become involved then please contact us.
Thank You for your interest in SPHERE, please visit our News page for updates, follow us on Twitter (@SPHEREreporting) or contact us for further information.