• We will support the foundations of the national strategy: a patient safety culture and a patient safety system, across all settings of care. 
• The PSCs will deliver the patient safety strategy improvements and seek the next tranche of national programmes for national adoption and spread. 
• We will work with our members, Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to roll out and embed these national initiatives in the local areas, ensuring ownership and sustainability. 
• We will work alongside the Regional Patient Safety Teams focusing on their system-wide objectives to support STPs and ICSs to identify and implement transformational change. Each region will have differing local needs depending on their starting point, but there will be cross-cutting themes that every PSC can support in a standardised way. Following the adoption and spread of the national initiatives, the AHSN network can support the seven regions with the national programme of capacity and capability building, utilising our local academies and delivery mechanisms for integrated quality improvement, Health Foundation training and innovation training. 
• We will support the capacity and capability and leadership development programmes particularly helping our local system leaders and partners to build knowledge and understanding of the innovation landscape and the opportunities this affords their own organisation’s and wider system’s safety agendas. 
• We will build on the operational and strategic relationships we have with other national bodies also interested and engaged in the world of patient safety. In particular, we will strengthen our partnership with:  
  • The Health Foundation (HF), which has supported the development of the early phases of a number of projects that have developed into national patient safety initiatives; 
  • Health Education England (HEE) to deliver the safety mandate, building on our existing relationship which sees us working together on joint programmes of work such as learning from deaths and the response to the Topol Review, focusing on the opportunities for safety from genomics, artificial intelligence (AI) and the digital revolution.

This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.

To date, the following learning points have been identified and explored:

• End of Life Care, ceilings of care and avoidable admissions
• Some investigations have highlighted cases where the End of Life Care pathway could have either been established or fully implemented, where this would have been of benefit to patients and their families. Some patients may not have been cared for in the right location, and some admissions could have been avoided if the End of Life Care pathway had been suitably established and followed.
• Early detection and response to physiological deterioration, and effective communication
• Response stretched by implementation of National Early Warning Score (NEWS) but still learning around effective communication of escalation. The use of standardised communication tools is essential.
• Record keeping and organisation of medical records
• Some learning was identified in relation to the accuracy and completeness of medical records. It was evident that not all records are reflective of the clinical picture.
• Discussion with specialty teams is vital to support the investigation
• An independent review by the ME should be further supported by speciality ‘experts’, and if possible, peer review from other trusts can be sought to allow for full independent review. Seeking speciality opinion from those not directly involved with the case within STHFT has also been shown to be effective.
• Pathways for links to wider clinical governance processes have been strengthened.

• Use various techniques to engage healthcare professionals.
• Make it fun.
• Make it relevant.
• Concentrate on wards where the risk is high but the AKI culture is low – this will result in a wider impact.

• Video outlining the background of PINCER.
• Resources for you to access - PINCER and PRIMIS information and help.
• PINCER Myth Buster Poster.
• PINCER Myth Buster.
• Using PRIMIS tools for quality improvement.
• PINCER 1 Query Library - Overview, analysis and interpretation.

Already deployed and delivering significant cost savings in 20 hospitals in Italy, the independent evaluation work – completed December 2015 – has confirmed that the use of “optimisation of medicines with individual dosing” (OptiMed-ID) in an NHS acute hospital setting can deliver drugs cost savings in excess of 25%.  Deployed throughout four wards at UHL, this is the first time that an automated individual medicines dosing solution has been brought into operational use in the UK.

The evaluation report has informed UHL’s decision to extend the pilot whilst business case and procurement activities for the rollout of the innovation throughout the whole trust are completed. The trust-wide deployment at Leicester is expected to deliver savings to the NHS of around £4m per annum, as well as improving medicines adherence and reducing the risk of medicine errors.

MedConNecT North have also facilitated further connections with clinicians, and Tookie are now working with the Great North Children’s Hospital in Newcastle with Dr Yincent Tse and Dr Heather Lambert, Consultant Paediatric Nephrologists. Together they have developed a paediatric version of the Renal Vest, which has also been CE marked.

In addition, Tookie Limited has been awarded an NHS Supply Chain Framework contract for Tookie products which is now live and has recently achieved ISO 9001 status.

The overarching aim was to reduce avoidable admissions to hospital from care homes. The Eastern AHSN believes this successful project is an easily replicable approach to the improved management or prevention of UTI and can directly impact by not only improving patient care with the added benefit of admission avoidance and reducing unnecessary clinical call outs.

Successful results and benefits:

• At the time of writing, 700 staff from 104 care homes across Norfolk have been trained in the management and prevention of UTI and how to complete the UTI checklist. Unplanned emergency admissions have reduced by 22% and a reduction in antibiotic prescribing has been seen within this cohort of care homes.
• Staff reported increased confidence in the management and prevention of UTI.
• Data from the checklists highlighted that a lot of UTIs were related to catheter management and obtaining samples from the bag, which became increasingly preventable from the change in treatment.
• Care workers were assuming residents had an UTI, but after the teaching sessions they realised it may be dehydration that could present the same symptoms and commenced re-hydration.
• If an UTI is suspected then the staff were taught to initially think dehydration and to increase fluid intake then to reassess the patient prior to making call outs.
• Care homes are not now doing routine urine dipsticks or using urine dipsticks as a diagnostic test to diagnose UTI’s which has improved our diagnosis of UTI.
• Feedback from care homes and primary care has been very positive with one care home manager emailing to say: “The UTI checklist is definitely used at our nursing home and we have noticed a positive difference since we started. Thank you for your support.”

The goals were to:

• support care homes in becoming internally and externally ‘well connected’ in the digital age;
• to enhance the quality of care experienced by care home residents, and by
• significantly improving communication between care homes and the external health environment.

This would provide better and more efficient cost-effective care. It had the following elements:

• to improve record keeping of care home residents by using tablet-based apps to allow electronic recording of aspects of care plans
• to train qualified and unqualified care home staff to make and record relevant clinical records (NEWS scores)
• to promote use of electronic communication of patient clinical information between care homes and primary care (GP electronic patient records), emergency care (including out of hours), and ambulance services and community services.

• Support teams across a wide range of health and care settings to improve their safety culture and quality of care.
• Increase the knowledge and understanding of the role safety culture plays in the delivery of high-quality care.

Top tips for adoption:

• The approach concentrated on the quality of the process.
• Word of mouth and recommendation was key.
• Awareness-raising of safety culture regionally generated interest.
• Public and patient involvement should be part of the process. Some teams have involved patients in their debriefing or improvement planning.

• PReCePT QI Toolkit PDF
• PReCePT Programme Implementation Guide
• PReCePT Clinical Guideline Flow Chart
• PReCePT Magnesium Sulphate Quick Reference Poster
• PReCePT Management of Preterm Labour Proforma
• PReCePT Magnet Instructions
• PReCePT Infographic Poster
• PReCePT Think Magnesium Too Poster
• Magnesium Sulphate Parent Leaflet
• Quality Improvement Learning Log (PDF)
• Midwife Lead Role
• Obstetrician Lead Role

• Aims, objectives and scope
• Method and approach
• Measurement plan
• Learning points
• Plans to spread the learning and adoption

• UTI hospital admissions reduced by 36% in the four pilot care homes (150 residents).
• UTIs requiring antibiotics reduced by 58%.
• The gap between UTIs increased from an average of nine days in the baseline period to 80 days in the implementation and sustainability phase.
• One residential home was UTI-free for 243 consecutive days.
• Similar outcomes noted in pilot 2 care homes (215 residents).