My experience of winning the Patient Safety Learning 'Culture' Award

Summary

Karen Harrison from Hull University Teaching Hospitals NHS Trust writes about her experience of winning the Patient Safety Learning Culture Award and what she plans to do next.

Content

I was invited to attend the Patient Safety Learning Annual Conference as I had been nominated for a Patient Safety Learning Award. Initially I had reservations about attending the conference as my inbox is constantly flooded with a myriad of ‘learning opportunities’ which have often not lived up to expectation.

My journey from East Yorkshire to London provided me with time to read Patient Safety Learning's ‘A Blueprint for Action’ safety strategy of which I was very impressed. As a leader in preventing pressure ulcer harms I welcome the drive to change the way we think about patient safety, especially the focus on involving patients and their families/carers to share their experiences and drive the shared learning.

The conference was excellent. The agenda was first-rate with the all the speakers showcasing excellent safety improvements. The engagement between speakers and delegates was thought-provoking and the use of interactive technology helped free thought and inquisitive questioning. 

My nomination for the Patient Safety Learning Culture Award was for the work I had done on Malcolm's Story. Malcolm's Story 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 and his family gave an honest and frank account of the care and treatment given to Malcolm.

Malcolm's Story was shown at the 2018 Trust nursing conferences and hearing their story in an audience of nursing and HEY staff was truly powerful and very emotional, especially as Malcolm and his family were in the audience. We believe the nursing staff in the audience really felt the message about how what may be seen as small failures in care can build up to cause significant harm, and long delays in a patient's recovery.

In addition to this piece of work, the nomination also featured my passion to create a lessons learned attitude towards all serious incidents. Over two years ago I wanted to 'do something different' to investigate why tissue viability serious incidents occurred as the usual investigation methods didn't always allow staff to feel safe to be open and honest. Along with the Organisational Development team we looked at new investigation techniques using the Yorkshire Contributory Factors Framework (YCFF) involving staff members to engage and learn about pressure ulcer harms differently. I hold team sessions which focuses 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 clinical and process issues for patients and understand what the wider contributory factors are.

I am extremely proud to have won the Patient Safety Learning Award in the category for culture. Involving Malcolm and his family and changing the way pressure ulcer harms are investigated has been pivotal in improving the culture around pressure ulcer prevention within ward teams and I extend my heartfelt thanks to all involved. It is also the start in showcasing the excellent patient safety journey Hull University Teaching Hospitals are on.

Next steps include embedding this style of safety investigations across primary and secondary care boundaries to challenge organisations to share YCFF learning events and to involve the patient and their families early on in the investigation. I will use the prize money to visit exemplar organisations who are already demonstrating this collective safety strategy.