Patient-Safety-Learning

There has been an big increase in the use of diabetes technology in the NHS recently, especially in type 1 diabetes. Continuous glucose monitors (CGMs) are now standard care for people with type 1 diabetes, and work has begun to increase access to hybrid closed loop (HCL) systems, which are sometimes referred to as an 'artificial pancreas'. Along with this expansion, it is important to raise awareness of these devices when people with diabetes are admitted to hospital, whether this is directly for their diabetes or not. This information poster, developed by Mayank Patel and the diabetes team at University Hospital Southampton, aims to raise awareness of diabetes tech devices. It also addresses the issue of safe insulin delivery, especially related to pumps.

Antidepressant medications are taken by millions of people globally. A small percentage of people who take them will experience rare but dangerous adverse reactions. In this interview, Katinka Blackford Newman tells us about her personal experience of antidepressant-induced psychosis and how this led her to campaign for increased awareness about side effects. She highlights a widespread lack of education and awareness about the risks associated with antidepressants and outlines why she is asking suicide prevention charities to ask callers one simple question about their medication.

The Patient Safety Management Network (PSMN) started on a Friday afternoon in June 2021 as three people in a Zoom meeting. In this interview, PSMN founder Claire Cox reflects on why the network has grown to have over 1600 members and what it has achieved over the past three years. She outlines how the network has fostered a safe space for staff to raise issues and shares feedback from members about what they love about the PSMN. The Patient Safety Management Network (PSMN) is three years old this month! What’s changed during the last three years? I originally set up the PSMN because I was trying to reach out to peers doing similar roles in different organisations. The Patient Safety Incident Response Framework (PSIRF) had just been released and we were thinking about how to apply it in our trust. I had questions I wanted to discuss, but there wasn't anyone that I could do that with. Although there was a patient safety specialists forum, I couldn’t access it because my role wasn’t senior enough at the time. So I started up my own! One of the pillars of PSIRF is meaningful collaboration between trusts and people, which is hard to achieve without something like the PSMN. Through the network, we’ve created a pool of people who are up for that collaboration. We now have members from 641 organisations and it’s important to note that they aren’t just from the NHS. Many of the members from outside of the NHS say they have real trouble trying to collaborate as they don’t know who to look for in an organisation. The independent sector finds accessing the same materials and information as the NHS challenging. When we first started the meetings, people would join them and sit quietly. Members were quite passive and expected to be presented to or taught something, which is why we ended up with quite a few outside speakers coming in, such as PSIRF early adopters. As the years progressed, I wanted the network to recognise that we are experts in our own right—as a peer group we can learn from each other and share our experiences. We focused on developing a trust that would allow people to feel safe to share their views. It's taken a long time, but we’ve moved away from people feeling like they need permission to share things that happen in their trusts. We’re not quite there yet though and I would still like to see people feeling even more comfortable to share their questions and insights. Interview continues below infographic How have you fostered that sense of trust within the network? We have always focused on creating a genuine safe space and consistent messaging has helped us emphasise that priority. At the beginning of each session, we go over our ‘ground rules’: We don't record the sessions Instead of taking minutes we write anonymised notes for members who can’t attend. We emphasise that hierarchy doesn’t apply within the network We ask people not to use acronyms. We encourage people to speak up if they want to and don’t put anyone on the spot. Members put their hands up if they want to speak and can use the chat function if they prefer. I say at the start of every meeting that if people don't like the session, they don't have to stay. That’s why the participants we have in each session are always different. People feel able to just take what’s going to help them do their job more effectively. Following our weekly discussions, unattributable notes and resources from the session, such as power point presentations and good practice information, are shared on the PSMN private community space on the hub, accessible to all Network members. Is there a particular session that has been a personal highlight? There have been a lot of highlights for me! When we have speakers, they always share amazing things. My favourite session with an outside speaker was when Dr Pip Hardy from Patient Voices came to speak about digital storytelling. Her message hit hard and people were very moved by what she shared. She ended up coming back to speak again because the first session generated so much helpful discussion. For me, the sessions that best embody what we want this network to be are the ones where we don’t have an external speaker—although they are also the sessions that cause me the most anxiety! I love it when members speak up and new people feel able to contribute, that’s where the magic happens. We witness cross pollination happening in real time, and that’s what I always envisioned the PSMN doing. Have there been things you have picked up from PSMN sessions that have changed the way you approach your role? Definitely—it’s often when you start doing things in your real-life role that you realise where the gaps are. One example that comes to mind is when we spoke about patient and family engagement a few months ago. At my trust, we were seeing a big gap in patient and family support once an investigation ends. Our contact suddenly stops at this point, and we weren’t sure where to signpost people. Patients and families were coming back and saying, “I have been harmed by this, what are you going to do about it? Where am I going to get my psychological support from now? How do I access counselling?” I realised I didn’t know the answers and neither did anyone in my department. I raised this during one of the PSMN meetings and a member piped up and directed me to someone who works for the South London ICB. This contact has a whole list of information that you can give patients, signposting them to further support. I got in touch with her after the session and she's given us a lot of advice about where to direct patients and families when our support comes to an end. Has the PSMN been able to have an impact on patient safety policy and practice? Before we set up the network, people in patient safety roles in individual organisations did not have a voice or any influence on what the safety agenda should look like. We now have a collective voice and are regularly asked for input into research and other initiatives from NHS England and the Health Services Safety Investigations Body (HSSIB). We now have over 1,600 members and regularly get around 100 people turning up to our Friday Teams sessions. In the early days there were three or four of us each week! As a group, the roles of patient safety people and the work we do, such as investigations, are understudied. Because of this, there are academic groups who want to come in and look at how we are applying the emerging safety sciences. We take part in some of these studies, but I screen out quite a few because we need to maintain a respect for our members and the patients that they serve. We tend to work with organisations with whom we have built a positive working relationship—for example, staff from Loughborough University and THIS Institute come in to look at what we're doing and ask for our input. HSSIB has also asked what we think about their training, which gives us an opportunity to help shape it. Senior staff from NHS England patient safety and national bodies regularly come to the sessions to share information, hear reflections and gain feedback from Network members. Our feedback is invaluable because we’re the ones using the current guidance, doing the training and implementing PSIRF. Some trusts are much further ahead and have applied PSIRF, while some are at the beginning of their journey and may be struggling with certain challenges. Our collective voice also gives a useful platform to ask the NHS England team what’s next for PSIRF. We’re raising important questions about how they are monitoring standards now they have set them and how trusts are going to be judged against them. PSMN members have also set up ‘spin-off’ networks which are developing as unique forums. For example, the Patient Safety Partners Network has offered important feedback about how the Patient Safety Partner role is evolving and whether it's working for trusts and individuals. It gives NHS England sight of something that they otherwise wouldn't see. The Patient Safety Education Network has also been a great success, set up specifically for those in patient safety education and training roles. In just under a year, it has already expanded to now have more than 400 members. What plans does the PSMN have over the next year? The network has grown exponentially over the past three years and now has a life of its own! It’s important to say that I’m not the ‘voice’ of the PSMN—all of its members are, as the experts within. Some exciting news is that some of the members of the network have written a book which will be published in August 2024. It is authored by network members who have written both the theory and the case studies. It has demonstrated that a real strength of the network is having both researchers and implementers—it's a symbiotic relationship that allows us to ensure our practice is grounded in research, and vice-versa. We are also holding our first network symposium in September which will include academic and in-house learning. At some point, I would like us to look how we can contribute to professionalising the role of patient safety specialists. We currently all have different job titles, pay scales and role descriptions and there is no parity between organisations. While I know that we've come from different backgrounds, we do need some kind of standardised training. At the moment there isn’t any, and that might be one area we could look to influence. That said, the network has a life of its own, so I don’t want to tie us down to specific aims or goals. The PSMN will go where it needs to go. It’s not my network, it’s ours, and I’m sure it will continue to change and morph into what it needs to be. What do members say to you about the network? As I’ve said, it’s important to hear direct from the network, so here are some recent comments members have shared with me: “When I started out in my role, the PSMN really helped me gain confidence, knowledge and a superb national network of safety leads and innovators. Two years down the line I’m still going, and it remains the highlight of my week. It’s not just the ideas, speakers and discussions that are useful, it’s also the way it exemplifies the best in terms of creating a psychologically safe space for sharing safety learning and improvement.” Patient Safety Director at an NHS trust "The network has been an excellent platform to learn from peers across the country. I have not come across any other platform such as this. I use it as my go-to for practical problem-solving ideas and there are always plenty of them, for all sectors. As someone who works in an ICB I am always looking for learning outside of my local system as well as getting ideas and solutions to the everyday business of patient safety and this platform gives us that and more. If you have not yest signed up, I encourage you to do so, it is a fulfilling hour each week.’’ Patient Safety Specialist at an Integrated Care Board “In the couple of years that I have been a member of the network, the PSMN has put me in contact with people of a similar mind from all over the healthcare industry. I have found a group where I can ask questions, suggest ideas and participate in discussions with no fear. The work spent creating the psychological safety is immense and this is one forum where there is no fear of judgement. I have learnt so much from each and every member of the network. I continue to be amazed at just how talented the patient safety people in healthcare are. The proof of the pudding is that this is a meeting on a Friday afternoon that invariably draws 70-100 people, and they look forward to attending—an immense success statistic in healthcare!” Patient Safety Education Lead at an NHS trust “The PSMN is an excellent forum for professional and lay people to come together and feel comfortable to be open and transparent about the concerns they have regarding the implementation of PSIRF, learning from incidents, learning from patient stories and above all wanting to ensure that patients, families and carers are at the centre of everything they do.” Patient Safety Partner at an NHS acute trust "The network has genuinely been an invaluable resource in my patient safety work. Not everyone in the NHS, I believe, truly 'gets' how we need to go about making patients safer, so spending time with a group of people who do feels like a breath of fresh air. The ideas, innovation and general support of this group has helped me in my career, and taking away ideas and trying them with my own teams, then feeding back wins and challenges has been so rewarding. It's honestly a joy to attend these sessions." Patient Safety Manager at an NHS acute trust Personally, I’d like to say a thank to you all those who support the PSMN, including AQUA, who assist taking notes at Network meetings, and BD who provided some tech setup funding for the private forum on the hub. I’d especially like to thank Patient Safety Learning, for hosting the Network on the hub and providing us with invaluable support to grow and develop the PSMN over the past three years. How to join the Patient Safety Management Network Do you work in patient safety? If you are interested in joining the Patient Safety Management Network, you can join by signing up to the hub today. If you are already a member of the hub, please email [email protected]. You can also find out more about the growing number of informal peer support networks hosted and supported by Patient Safety Learning. These networks now include: Patient Safety Education Network – a peer network for those in patient safety education and training roles. Patient Safety Partners Network – a group for Patient Safety Partners, paid and voluntary roles within NHS organisations aimed at improving patient safety. National NatSSIPs Network – a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Patient Safety Paediatric Leaders Network – an invited network for anyone who is a strategic-level decision maker in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality in the UK. The networks provide a forum for people involved in patient safety to meet up, share ideas and initiatives and learn from others. Related reading Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox) Patient Safety Spotlight Interview with Jordan Nicholls, Serious Incident, Quality Improvement and Governance Lead Patient Safety Education Network The voice of the patient safety frontline—An introduction to the Patient Safety Partners Network

Although healthcare worker violence ranks high among today's top patient safety concerns, healthcare workers continue to be harmed, and healthcare has been identified as the profession with the highest percentage of nonfatal workplace violence injuries. Over the last few years, a Pennsylvania facility found that assaults on nursing in their acute care organisation were more than double the national rate. In the webinar, Loni Francis, MSN, RN, director of Behavioral Health Services, and Erin Marinchak, MSN, RN, senior director of clinical practice, Reading Hospital, Tower Health, will explain how proactive rounding by internal experts an prevent assaults and how behaviour management plans can reduce physical assaults. Register for the webinar This event takes place at 12:00 EDT and 17:00 BST