Patient Safety Learning

Notes attached from the Patient Safety Partners Network meeting on 2 April 2024.

This month, the PSPs shared their recent successes. The discussions highlighted some common themes:

• The role of the PSPs, particularly at Board level meetings and on committees.
• What’s our function? Were do we sit?
• Advocates not only for patients but also for the staff.
• How can we measure impact?

PSPN meeting notes_2 April 2024.doc

Helen Hughes, Patient Safety Learning’s Chief Executive, highlighted that the PSP workshop next Wednesday in Birmingham still has a few places if anyone still wants to attend. Email helen@patientsafetylearning.org if you’d like to attend.

The current consultation on Never Events was highlighted as something the group might want to contribute to. https://www.pslhub.org/learn/organisations-linked-to-patient-safety-uk-and-beyond/government-and-alb-direction-and-guidance/nhs-england/nhs-england-never-events-framework-consultation-closes-at-midnight-on-5-may-2024-r10931/ Deadline 5 May 2024. 

Please add any topics you'd like to see discussed in future meetings in the comment box below or add your name if you would be happy to Chair a future PSPN meeting.

@ClaraR_ose Thank you for sharing your experience.

I am so sorry you went through such pain. 

At Patient Safety Learning we continue to call for more research and training in this area, and for all pain management options to be consistently offered to, and discussed with, women undergoing IUD procedures.

Most importantly we are calling for women to be listened to and their experiences routinely captured by health services so the extent of these experiences can be fully understood.

We have featured on the hub a couple of research projects around painful IUD procedures. Although both have now closed, I've copied the links below as both provide contact details from the leads on the research if you wanted to follow up with them and speak to them about their research and campaigns:

Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav)

The pain of my IUD fitting was horrific…and I’m not alone

From the Campaign Against Painful Hysteroscopy Facebook Group:

"According to NHS England's 'Getting It Right First Time' plan hysteroscopies will be done in Women's Health Hubs independent from hospitals. So what will that mean for women who'd prefer not to be awake during hysteroscopy? We need to ask NHS England."

An article in The Times over the weekend:

The ‘unnecessary’ NHS teeth extractions that led to lifetimes of pain (thetimes.co.uk)

Article in the Big issue:

NHS England's Patient Safety Partners Mentors handbook is attached. 

20220117 PSP Mentor Handbook.pdf

The most up to date version can be found on NHS Futures online platform at https://future.nhs.uk/NHSps/view?objectID=156996165

National Patient Safety team PSP FAQs (version August 2023) is attached below. 

PSP FAQ Aug 2023.docx

These will be periodically updated on the NHS Futures platform, so to ensure you have the most recent version please use the link: https://future.nhs.uk/NHSps/view?objectID=175274085.

Framework for Involving Patients in Patient Safety is on Future NHS and is a collection of very extensive resources not ‘formally published’ but include case studies on engagement, remuneration, Trust and ICB PSP Job descriptions/remuneration/PSP agreement, etc. To access, you need to join the Future NHS platform. It’s possible for PSPs to join although it’s a bit trickier to do without an NHS email address. With persistence, it can be done!

"Hysteroscopy without anaesthetic like being flayed alive" 

Hysteroscopy is in the news today. A woman from Wales describes her horrific experience of undergoing a hysteroscopy with an anaesthetic.

Notes from the PSPN meeting on 9 October 2023

The meeting started with a discussion about the level of awareness of PSIRF amongst patients, families and carers, what trusts are doing to raise awareness and when patients should be given information. The conversation then focused on how to communicate compassionately with patients and families and ensure their priorities and expectations are listened to.

Members also discussed the variation in how Patient Safety Partners are being recruited and contracted by trusts. There was discussion about ensuring independence from the organisations PSPs are working with. There was then a wide-ranging conversation about the extent to which PSPs should be involved in PSIRF training, engaging with patients, contributing to investigations and having a strategic input. There was a general sense that it was helpful to hear from PSPs working in other trusts to understand this variation, share ways of working and raise concerns and issues.

Download the full meeting notes:

PSPN notes 9_10_23.docx

Notes from the PSPN meeting on 5 September. Chaired by Chris Wardley.

Patient Safety Partner Network meeting notes_05Sept23.doc

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.