Top Picks: Key resources for patient safety managers working in hospitals

Summary

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. 

the hub's Content and Engagement Manager, Steph O'Donohue, has hand-picked 20 resources, particularly relevant for patient safety managers working in hospital settings. Shared with us by hub members and patient safety advocates, they are jam-packed with practical tools and rich insights. 

Content

1 D1abasics: Equipping staff to care safely for inpatients with diabetes

The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital.

2 Yellow kits - an innovation to reduce the risk of falls in Accident and Emergency departments

In this blog, Jayne Flood, Falls Prevention Practitioner at East Kent Hospitals NHS Foundation Trust, describes how her team introduced ‘yellow kits’* to assist patients at high risk of falls in A&E, and evaluated their impact.

3 A simple guide to the Patient Safety Incident Response Framework (PSIRF)

This guide provides information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident.

4 National campaign aims to reduce patient harm from infiltration and extravasation

Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and  cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and  extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety.  

5 Infiltration and Extravasation: A toolkit to improve practice

This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations.

6 Medication delays: A huge risk for inpatients with Parkinson’s

In this blog, Laura Cockram, Head of Policy and Campaigning at Parkinson's UK talks about the serious health implications of medication delays for people living with Parkinson's disease. She also offers recommendations for how hospitals can reduce the risk of harm.

7 Application of SEIPS and AcciMap to a patient safety incident

Chris Elston, a patient safety education lead, shares how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from a patient safety incident at his Trust.

8 Improving safety for diabetic inpatients: 4 key steps

In this short film, National Specialty Advisor for Diabetes, Partha Kar shares four steps for improving the safety of diabetic inpatients.

9 Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies

Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of losing her son to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the need for greater awareness and a widespread review of policy in order to prevent future deaths.

10 Appreciative inquiry case study

Appreciative inquiry is one of the Patient Safety Incident Response Framework (PSIRF) tools that can be used to learn from patient safety incidents. Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares how she designed and introduced an appreciative inquiry tool at her hospital.

11 Measuring standards of care, not negative outcomes

In this interview, Gavin Portier, Head of Nursing Quality, explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. Gavin shares related resources and some of their early results. 

12 Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital

Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model, developed by Theatre Nurse Carole Menashy, is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. In this series of blogs, Carole explains how and why she set up the support service.

13 NHS Mid and South Essex's 'We're Listening' leaflet

Danielle, Critical Care Outreach Nurse, share's her 'We're Listening' leaflet as part of the trust's Call for Concern service. This service has been developed so that patients, friends and family can alert the Critical Care Outreach team if they have concerns that need listening to and gives a telephone number to call and outlines the next steps.

14 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff

Sam Goodhand, a registrar specialising in anaesthetics and intensive care medicine, explains why he designed and printed simple checklist cards to help reduce life-threatening complications occurring during adult and paediatric intubation procedures. He shares details of how to order the cards for your area. 

15 Tackling antibiotic underdosing: Interview with Ruth Dando, Head of Nursing for Theatres, Critical Care and Anaesthetics at BHRUHT

In this interview, Ruth Dando, Head of Nursing, Theatres, Critical Care and Anaesthetics at Barking, Havering and Redbridge University Hospitals Trust (BHRUHT) explains why antibiotic underdosing is a risk to patient safety and describes how she has implemented a change in practice to tackle the issue across BHRUHT.

16 Duty of Candour: Frequently Asked Questions

These FAQs on the Duty of Candour were produced by the Patient Safety Management Network in collaboration with experts from the Care Quality Commission (CQC) and NHS Resolution, and address the most pressing concerns about Duty of Candour.

17 Embedding Martha's Rule into practice—Lessons from the national pilot

Martha’s Rule is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon.The Royal Manchester Children's Hospital's (RMCH) was one of the pilot sites during the first year of the Martha's Rule pilot. This blog outlines the hospital's efforts over the past year to integrate Martha’s Rule into everyday clinical practice, aiming to empower staff and families to raise concerns effectively on patient deterioration.

18 SEIPS in practice

In this blog, Associate Director Claire Cox shares a video training resource developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action.

19 Implementation of bedside electronic transfusion checks at Barts Health Trust: Quantifying benefits

Laura Green, Consultant Haematologist at NHS Blood and Transplant and Barts Health NHS Trust, describes how a new electronic process to improve the safety of blood transfusions was implemented across all four Barts Health sites. She explains why the new system was needed, outlines the benefits for staff and patients and highlights the role of project governance and staff training in successful implementation.

20 Speak Up for Safety: A new workshop for healthcare staff about the importance of Just Culture

The culture of a healthcare organisation can determine how safe its staff members feel to raise concerns about patient safety. Bella Knaapen, Surgical Support Governance & Risk Management Facilitator and Sarah Leeks, Senior Health & Wellbeing Practitioner at Norfolk and Norwich University Hospitals NHS Foundation Trust, have developed ‘Speak Up For Safety’, a Just Culture training workshop that aims to help staff, at all levels, understand the importance of creating an environment that encourages people to share concerns and feedback. In this blog, Bella describes why they thought a training course was needed, outlines the approach she and Sarah took to develop the workshop and introduces the topics covered.

#Share4safety
Have you set up an initiative or made changes locally to improve safety? What were the challenges and successes? Are there any tools you've developed that may be useful to share with others? 

Why not get in touch with us at [email protected] to tell us more and share your insights. Perhaps you'll be in our next Top Picks! 

Patient Safety Management Network
Some of our members have recently come together to set up a collaborative network for people working in patient safety roles to support one another and share ideas. They currently run weekly drop-in sessions. 

If you'd like to join the network, simply sign up to the hub (for free) and tick the box for the Patient Safety Management Network. Make sure you fill out the 'about me' section to highlight how your role is relevant to the group. 

Stephanie O'Donohue, Content and Engagement Manager