Patient Safety Learning

Slide deck from a recent facilitated workshop on PSPs:

PSP workshop facilitated slides 210723.pptx

NHS England » Patient Safety Incident Response Framework and supporting guidance

Contains documents on:

• Patient Safety Incident Response Framework
• Engaging and involving patients, families and staff following a patient safety incident
• Guide to responding proportionately to patient safety incidents
• Oversight roles and responsibilities specification
• Patient safety incident response standards
• Patient Safety Incident Response Framework - Preparation guide
• Patient safety incident response policy and plan templates

Presentation Deborah Carter, Patient Safety Project Director at Warrington and Halton, gave last year:

Warrington and Halton Teaching Hospitals PSP planning workshop July 22 (2).pptx

Other example JDs:

PSP Role Description Birmingham Community Healthcare.pdf

PSP Role Description Royal Berkshire (1).pdf

Presentation from Solent NHS Trust on evaluating the implementation of PSPs:

PSP Role Evaluation Presentation Solent.pptx

And related appendices:

• Checklist for PSP involvement
• Expense claim form for PSPs
• Patient safety partner agreement
• Patient safety partner role description
• Equality and diversity monitoring form
• Patient safety partner (PSP) application form
• Patient safety partner induction checklist
• Patient safety partner regular one-to-one form
• Declaration of interests

Copy of the Patient Safety Partners guide

Easy-Read-Patient-Involvement-Framework-26Jul21.pdf

Patient Safety Partner Template Role Description:

B0435-app-patient-safety-partner-role-description.docx

Presentation from NHSE on 'Approaches to recruiting Patient Safety Partners':

NHSE PSP Options for Recruitment.pptx

Link to the NHSE Framework and copy of the driver diagram

NHS England and NHS Improvement: Framework for involving patients in patient safety (29 June 2021)

Hi @Illumi123

So sorry to hear of your horrific experience when you went to get an IUD fitted. No-one should have to experience this type of pain. Although many women have only mild discomfort when they have an IUD, as you can read from this thread, many like yourself have a much worse experience.

If possible, please do speak to a trusted friend or adult about you concerns and experience. We would also encourage you to go and see a healthcare professional, potentially with a friend or trusted adult for support, to discuss your concerns and the pain relief options that are available to you. Having more information may help you feel in a stronger position when the time comes to have your IUD removed. Also, if possible through school or the community, it may be helpful to speak to a counsellor about how you may be able to manage your fears in relation to this if this is something you would feel comfortable doing.

Please continue following this thread as there may be a healthcare professional or patient who has gone through something similar who could advise you further on the options available to you in the US.

Thanks for sharing Sian.

We have some resources on the hub from AHRQ on TeamSTEPPS which uses CUS if hub members want to find out more: 

AHRQ course- TeamSTEPPS® for diagnosis improvement

AHRQ - TeamSTEPPS teamwork system

AHRQ: TeamSTEPPS® – tools and tactics for good teamwork

I'm sorry to hear that @Blodwen

There should be procedures in place at the private hospital to raise concerns directly with them as a complaint. 

However, if you have tried that and got nowhere, I would advise you to take a look at the AvMA website which provide clear and straightforward information on the steps you can take and guide you through making a complaint: 

AvMA - Complaints about NHS or private healthcare

Also, PHIN has information on making a complaint as a private patient:

PHIN - Making a complaint as a private patient

I hope that helps. 

@Anne1010 I'm so sorry to hear that your last procedure was a painful experience and can understand your fears for the hysteroscopy. If you take a look at the comment posted in this thread by @Katharine Tylko on the 6 August (a few comments up) it gives the guidance from the RCOG on hysteroscopy procedures. It also highlights the facebook group -  Campaign Against Painful Hysteroscopy - which might be helpful to you and offer support and advice.

A new blog, published on the hub, tells the story of Jenny who passed away from pulmonary embolism, having been misdiagnosed.

Her son Tim is campaigning for improvements in pulmonary embolism awareness and care to reduce the risks of misdiagnosis. 

Have you, or someone you know, been affected by a pulmonary embolism? 

Was there a misdiagnosis? 

Please share your experiences, and thoughts on Tim's blog, in the comments below. 

You'll need to be a hub member to comment below, it's quick and easy to do. You can sign up here.

Hi @Momof2

I have copied your post into our hysteroscopy thread. You'll find lots of information in there and there may be someone who can advise.

Painful hysteroscopy

Some more examples of hospital's Call 4 Concern leaflets:

• University Hospitals Dorset - Call 4 Concern leaflet
• University Hospitals Sussex - Call 4 Concern leaflet
• East Suffolk and North Essex - Call 4 Concern
• County Durham and Darlington - Call 4 Concern leaflet
• Call 4 Concern leaflet - Royal Berkshire NHS Foundation Trust
• Call 4 Concern: Frimley Health

We'd love you to share yours. Just add it to the comments field below.

@AmaniKrayem Thanks for posting. We will share on social media.

Extremely painful hysteroscopy | Care Opinion

@Alison R @Barbara Arroyo @David Watts @DawnP @Steve Turner

On 11/05/2022 at 14:11, Guest Anon said:

Prior to attending a hysteroscopy appointment, I looked up other patient experiences and read through the personal testimonies on this website.

I stopped reading after the third one, anxious about my coming procedure.

I telephoned the hospital to discuss pain relief and the level of discomfort and they reassured me that if at any point it became too painful they would stop.

With some trepidation I loaded up on painkillers, - paracetamol and codeine combined with ibuprofen and made sure I was not driving.

Hoping for the best but planning for the worst, I was relieved to find the procedure straightforward, a little uncomfortable, and almost pain-free.

The removal of the polyps gave a momentary stab of pain but really very little. To have had a general anaesthetic would have been more problematic, time consuming, and no doubt higher risk.

Whilst I do understand the need to convey bad experiences, it is important to let people know that for many women this may not be a particularly traumatic experience.

Creating the expectation of extreme discomfort and pain may be counter-productive as the stress and anxiety prior to the procedure will almost certainly contribute to the discomfort experienced.

Some hours after, and back at home, I I feel back to normal and I’m experiencing no discomfort or pain.

It's good to hear that you had a positive experience and you're recovering well. Many women have no pain or mild to moderate pain.  However it's important hospitals follow the RCOG guidance and do offer general anaesthetic from the outset if that's what the woman wants, and stop the moment the patient is in pain. Women should be given all the information and options so they can make an informed choice. Unfortunately this isn't always the case.

Thank you for sharing your experience.

An investigation by The Sunday Times has found that the drug sodium valproate is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings.

Sodium valproate, has been given to women with epilepsy for decades without proper warnings, and has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain.

The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be given financial redress.

Read the Twitter thread from Rebecca Bromley who has been working with families who have suffered:

Have you attempted to access treatment for a urinary tract infection (UTI), or recurrent UTIs? We'd love you to share your experiences with us.

• Did you feel listened to by your doctor or healthcare professional?
• Did they take your symptoms seriously?
• Did you receive timely and appropriate treatment?

I was subjected to an excruciating hysteroscopy in outpatients without being made aware of all the pain options. I was denied local analgesia when I asked about it beforehand and told it wouldn't be necessary as the pain would be slight cramping. It wasn't.

I noticed some light spotting about 6 weeks ago. I reported this to my GP, who sent me for an internal ultrasound. This identified slight thickening of the lining of my uterus (7mm), so I was sent for a hysteroscopy at Nevill Hall hospital, in Abergavenny. I received a leaflet in advance, which said 'some patients experience discomfort. If you find the procedure uncomfortable, please discuss this with the clinician'. it also stated that one of the frequent risks was pain. However, on the same page it said 'You will be offered local analgesia', so I didn't worry too much.

When I met the clinician in advance of the procedure, he explained any discomfort would be like period cramps. I asked about pain relief, but he repeated it would just be like period pains, if I experienced any pain at all. As I used to have dreadful period pains, have had coils inserted and removed, and have given birth naturally twice - once without pain relief - I thought I'd be fine with this. I'm usually pretty tough when it comes to pain, in any case. 

When the procedure started, I felt some discomfort when the hysteroscope went through my cervix, and remember saying 'Ow'. Then the most incredible, searing, tearing pain I have ever experienced - I guess it must have been the pressure of the saline. I found the arms of the bed to grab onto, and could hear myself shouting -No no no no no, stop stop stop-. The plan had been to take some pictures, followed by taking a sample of the lining of my uterus lining, but the clinician stopped the procedure having had a look and taken some pictures. They may have spoken to me and asked questions during this time, but I have no recollection of anything except the pain. When I finally opened my eyes, the clinician was nowhere to be seen, and the two nurses were asking if I was OK. I was extremely shaken and very out of it, from the pain and the shock.

After I'd recovered for a few minutes, still with my legs in the supports, and lying back in the examination chair, the nurses told me I should go and get dressed, which I did, very shakily. They then showed me out of the room to the clinician's room opposite. Another doctor was standing in the doorway of his office, and I wasn't asked in, or asked to take a seat. I just stood in the doorway, still dazed and very shaken. The clinician looked up at me from his desk and said everything looked fine and joked that he would give me a 10 year warranty, as all seemed in order. The nurse then pointed me towards the exit door and I was on my way out of the department, to drive myself home. There was no offer of anywhere to sit and recover. I felt a complete wimp, and as if I'd made a terrible fuss about nothing. And very confused. As I mentioned earlier, I'm usually really brave but this was the worst pain I'd ever experienced.

I had phoned the hospital the day before the procedure, as I'd noticed in the patient leaflet that it said I needed someone with me to take me home. The person I spoke to said that was because I would be given local anaesthetic, and if I had an accident on the way home, my car insurance would be invalidated. She said it was at my own risk if I attended on my own and drove myself home. Having driven many times after local anaesthetic, coming home from the dentist, I took the decision to attend the hospital on my own, as it was short notice to find someone to drive the 40 mile round trip, and I wanted this done as soon as possible in case there was a risk of cancer. As a result of this conversation I had fully expected to be given a local anaesthetic for the procedure. 

I got home and looked up 'Painful Hysteroscopy' online and was appalled (and partly reassured) to see that up to 25% of women experience severe pain. I had no idea there was an option to have this procedure done under general anaesthetic, although I probably wouldn't have gone for it anyway, as I was only expecting period pain type cramps. I have regular lower gastrointestinal endoscopies and sigmoidoscopies without anaesthesia and bear the discomfort pretty well. So I assumed this would be similar. 

I have gone from being pretty fearless and confident to being terrified of going back. I wrote this on the day it happened while it was still fresh in my mind.

63 year old woman. Procedure 16 Sept 2021 at Nevill Hall Hospital, Abergavenny

There are a number of initiatives for walking frames.

Medway NHS Foundation Trust have teamed up with their orthotics department to use Funky Frames. Staff can order a Funky Frame kit which contains the yellow lagging and various coloured tape. It can be removed once the patient is discharged. 

https://www.nursingtimes.net/news/hospital/trust-to-pimp-walking-frames-to-try-and-reduce-falls-07-04-2017/

And users at Coverage Care’s Woodcroft home in Market Drayton have been personalising their walking aids by spray painting them different colours including pink, orange, blue and purple or decorating them with stickers so they can easily identify their own frame.

https://www.coveragecareservices.co.uk/news/pimp-my-zimmer-project-to-reduce-falls-at-shropshire-care-home/

You may also be interested in a recent interview we did with two dementia leads at Sussex Community NHS Foundation Trust on keeping patients with dementia safe.