Patient Safety Learning

Lots of discussions on Twitter on the guidelines. Don't forget consultation closes 13 March.

@Cath MarslandPlease try this link: The Patient Safety Incident Response Framework (PSIRF) (brownejacobson.com)

or I've attached it here for you to download

the-Patient-Safety-Incident-Response-Framework-08112022.pdf

Thank you for sharing Richard. I've added the page to Learn:

Royal College of Emergency Medicine: Safety Resource Centre - Emergency medicine - Patient Safety Learning - the hub (pslhub.org)

@Aoife McCarthy Hi. The link should now work.

@Barbara Hercliffe The page appears to have been removed from the NHS Resolution website but the pdf is still available. I've updated the link

Did-You-Know-Extravasation.pdf (resolution.nhs.uk)

Hi Arsha. I've also posted your comment in the Patient Safety Manager Network group as I'm sure some of the other members of the Network can answer:

https://www.pslhub.org/forums/topic/233-what-platformstechnologies-are-you-using-to-share-procedures-within-your-organisation/

@richard vA  to protect ‘Susan’s’ confidentiality we won’t be able to connect you but we will let ‘Susan’ know so she can get in touch with you if she wishes to. Thank you for your comments.

@Swoo Great resources! Thanks so much for sharing. We'll get all these up in Learn.

@Dr Charles Shepherd Thank you for sharing these resources and tips with us. We've added your guide to our Learn library so others can use it: https://www.pslhub.org/learn/coronavirus-covid19/tips/me-association-post-covid-19-fatigue-postlong-covid-19-syndromes-and-post-covid-mecsf-september-2020-r3623/

I've also linked this comment to our community conversation on long covid: 

Please do share any other resources you have on long covid and also on ME/CFS or if you would like to write a blog on this we'd be happy to post it on the hub. 

Hi @Jen L I've just privately messaged you through the hub with the documents attached. Let me know if you still have problems opening them.

Dr Rick Fraser asked us to post his response to this blog:

Good to hear about the work you are doing.

An open/transparent culture of speaking up is something I am really interested in for so many important reasons - I have found the IHI model of safe, reliable and effective care is enormously helpful in linking patient safety and culture.

When an organisation has a culture where psychological safety is clearly evident then staff, patients, family & others all feel able to speak up and raise concerns as & when they occur. The organisational response is crucial and needs to be absolutely linked to patient safety as that cannot be disputed and is always the common ground we look for when trying to connect across systems and with others eg staff.

An authentic, consistent approach that is humane, proportionate and transparent is crucial and must be led from the Board all the way through the organisation. Included in this humane approach are kindness, forgiveness, fallibility and equality. Some of these will come naturally and others have to be nurtured within individuals and the organisation. Some may criticise and call it 'woolly' or 'fluffy' however when the evidence can link all of these culture based approaches patient safety and outcomes then there can be no dispute.

That’s what is so elegant about the IHI model (below) as it links all these aspects of the system together and allows for development of culture & learning system and then ongoing monitoring from Board to Ward. As a Dr this makes perfect sense as it combines the science/evidence with the learning system/culture to ensure patient care is optimal and safe every time.

Dr Rick Fraser, Chief Medical Officer 

Thanks Alex for your comment. We'd love to hear from and publish other view points to our posts. If anyone would like to write a blog to go alongside any of the hub posts please get in touch content@pslhub.org

Recent tweet:

Hi Mary @Mary Thank you for your post. You may be interested in reading the blog we recently published "COVID-19: What are you wearing" and the conversations following it: 

@Kathy Nabbie @Claire Cox

Hi Kirsty

This was produced by Antonia Field-Smith. Perhaps try contacting her via Twitter: 

Article on this in HSJ with some interesting comments following:

https://www.hsj.co.uk/primary-care/gps-contacting-patients-about-do-not-resuscitate-forms/7027279.article?mkt_tok=eyJpIjoiTkdOaE56VmlNMk15WVdFeiIsInQiOiJvVUpmOHlVaDRJUGlaUit3RG80dTFrbFhaOW91eFwvM1pGQ1F4UFlGWU9KeTU1Q0Q0cDZ6dUVPM3p4cnJGdWRkR0t2NFhza3hvZ2wzN3hMS0FuK3cwTkNkVlR6bExVOWlRNlMrQkYyZ1wvRzlHWlBTSm5QQWdzSmNRQ3VwVHkxZTBnIn0=

@Gary Saunders Any thoughts?

Scan4Safety is an initiative led by DHSC - @Richard Price I believe the University Hospitals Plymouth NHS Trust is using this?

Another great blog @MartinL! Thank you for sharing. You may be interested in another blog we published today from an anonymous nurse. She is frustrated at the lack of outcomes and learning  from reporting at her hospital...

https://www.pslhub.org/learn/improving-patient-safety/stories-from-the-front-line/florence-in-the-machine/marking-your-own-homework-r1726/

@janieb Hi Jane. I'll email them over to you now. I've also added a pdf version of the powerpoint which is a smaller file size so should be easier to download.

Thanks for sharing this inspiring initiative Carol. Does your Trust have something similar? Follow the link and join in the conversation taking place in our Community area on Second victim.

Thank you for sharing such a candid account at what must be a very difficult time.

If you have a story to tell, please do share it with us on the hub. By sharing our experiences, we can start having honest conversations around these topics.

Another great blog, thank you Martin! 

If you've been involved in investigations or are experienced in human factors we'd love to hear your feedback on the blog. 

@HelenH I've just added it to the community - would love to hear others' thoughts and suggestions: 

What a great idea! Has anyone done something similar in the UK? Visits to zoos, aviation, construction...