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  • Malcolm’s story and learning from incidents: Winner of the 'Culture' category 2019

    Patient Safety Learning
    • UK
    • Safety improvement strategies and interventions
    • New
    • Everyone


    Malcolm's Story, produced by Karen Harrison, Tissue Viability Nurse at Hull University Teaching Hospitals NHS Trust, is a video of Malcolm, his daughter and his wife sharing their experiences of Malcolm being a patient in our Trust and developing a hospital acquired pressure ulcer while in our care. 


    Malcolm's story was produced through the drive and determination of Karen Harrison. Karen knew that there was a huge amount of learning to be taken from this particular case, and wanted to create something positive from the mistakes made. Karen supported Malcolm and his family through the whole process, from building a relationship while Malcolm was an in-patient through to developing the video with the family. Karen showed care and compassion to Malcolm, his wife, and daughter throughout the whole process, and their trusting and warm relationship was evident through the video and when Malcolm and his family thanked Karen for her support. 

    Karen wanted to to create a lessons learned attitude towards all serious incidents. Over two years ago she wanted to "do something different" to investigate why tissue viability serious incidents occurred as she noticed that the usual investigation methods didn't always allow staff to feel safe to be open and honest. They were often a scary experience and the action plans they created were not having the impact on the ward to fully embed the lessons that needed to be learned. She contacted the Organisational Development team for support as she wanted to try something new. Instead of the usual individual interview she wanted a team facilitated team event so that they could together understand the patient journey. 

    A team session focused on allowing individuals within a team to see what happened to the care the patient received with a wide angled lens versus their individual memories of the patient and incident. It also allows us to explore issues that are wider than just the clinical and process issues for this patient and understand what the wider contributory factors are.



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