HelenH

Just ordered your 'The Below Ten Thousand' book. And then the amzing @Claire Cox has shared her copy with me. Great stuff! Can't wait to read. Creating the image. That's a really intesting concept and soemthing we should think about too @Sophie Caswell Really awful that clinicians need to be brave. Think @Claire Cox is developing a blog on courage. Won't it be wonderful when all staff and patients are actively encouraged to identify areas for improvement and new ideas are celebrated , actioned and shared?

Hello everyone, We know there is much learning to be gained from listening to patient and families. This is particularly true when it comes to patient safety. Have you had an experience that you'd like to share with us? Maybe you identified a risk or shared a concern and were listened to and unsafe care was avoided? Maybe you weren't listenied to or you didn't realise what was going on and you or your family member were harmed? How did you find out about the patient safety incident? Was information shared with you that you needed to know? Were you supported? Was there an invetsigation into the incident and were you invited to contributed to it? Were lessona learned and acted upon? Have others learned from this experience, do you know?

And great to be able to share for World Sepsis Day too. Thanks @Ron Daniels

Judy, an excellent article, thank you. A lot of guidance on formal invetstigations in healthcare but not AARs. Such a missed opportunity. Do you think healthcare organisations will share their AARs? It would be fantastic to learn and share from these. Helen

Hi @Ben Tipney, the more I learn about effective safety management systems the more I understand how related everything is! I agree that Professionalising Patient Safety is so vital - having specialist knowledge and capacity to support the design of safer systems, analysing data, improving services and safety and evidencing that change from reporting and shared learning. Expecting over-worked clinicians to report incident and near misses when they don't have the time or confidence that anything will happen with the data will make reporting rates per se an unreliable indicator of safety performance. And with regard to professionalising patient safety, I don't think we have standardised role descriptions, competency frameworks and person specifications for patient safety roles. Or do we? Does anyone know whether these have been developed and if so where these might be?

Aine, i hope you find this useful

Wow, impresive work, Luke. Thank you so much for sharing the journey and the learning on the development of the App. It seems that core to this is clinical leadreship (yours and the team) and partnershop with BD (copying to @Simon Noble-Clarke )and others - and the alignment between national initatives and local implementation. We will be interested in how this gets taken further and the models for implementation and spread. How might we help? You might be intersted in this @JULES STORR We're meeting with NHSX soon and this sounds exactly the sort of innovation that adds value and for safer care. Great that you've had such recognition. Have you thought of putting in for one of our awards? @Claire Cox will send you details of these for sure! Tricky question, now. If you had to quantify evidence of impact, patient safety, staff engagment, finnacial etc, what would you say? Thanks again, Luke

Hi Danielle, Thanks for your post, really interesting and congratulations on the initiative. It's clearly been a huge effort and so much in your personal time too. We know that effective team work and communication are so important to patient safety but it's always a challenge to be able to demonstrate impact on clinical care. I wonder what research has been doen on this area? It would be great to capture other newsletters too - to similarly inform, inspire and improve practice. What do others think? And do share more! Thanks again Danielle and for taking the time to share with us. @Sam just a thoughts - does this conversation automatically get picked up in the community discussion? @Margot Can we tweet about this and link people into th econversation?

Hi all, I had a great meeting with @Neal Jones yesterday and in a wide ranging discussion we reflected on design and human factors. I recall some great work many years ago on the redesign of ambulances (that the NPSA contributed to) and wondered what happened to that initative and whether this had developed into designing new hospitals for patient safety. @Neal Jones recalled the DOME (designing out medical error) project http://www.domeproject.org.uk/index.html. This web site is dated 2010 and it seems to have been a three year funded project. Is this innovative approach still 'live?' Does anyone know of any work on human factors in hospital design to deliver safer care (processes, equipment, layout, technology etc)? In the UK or internationally? By googling I've found articles on specific departmental inititaives and people calling for more to be done but not much of the 'how' or any requirment to embed patient safety into new build hospital deisgn. Surely there must be soemthing?!!

I once raised with a very senior leader that our approach to managing complaints wasn't leading to learning or action to improve care. I was admonished and clearly told (the words are embedded in my brain) that 'we are managing complaints not doing patient safety.' At that point I knew I had to leave the organisation and that despite best endeavours, a resistant and closed-minded leader would not deliver the change that was written in the organisational strategy. On the scale of courage, it's pretty low compared to clinicians who whistleblow but it had a profound effect on me. From that day onwards I was effectively hounded out of the organisation for challenging 'the system.' Things worked out in the end but it was an interesting change in career that I hadn't planned. How much worse it must be when raising concerns/making suggestions for improvement with your employer challenges your job, future career and livelihood. I wonder how many staff would 'speak up' and share their views if they felt safe to do so and confident that their insights would listened to and acted upon. 1% of staff, 5%, 20%, more? What do people think?

@alisonleary brought to our attention a recently published book 'Courage in Health Care: A Necessary Virtue or a Warning Sign.' https://books.google.co.uk/books?id=kh1oDwAAQBAJ&pg=PT127&lpg=PT127&dq=courage+in+healthcare+shibley&source=bl&ots=HfVtxfDZMo&sig=ACfU3U2s3gecKAelqt1vyBwgeENO4HbgSw&hl=en&sa=X&ved=2ahUKEwiPmbD7jsHjAhVQyqQKHWZxAScQ6AEwBHoECAkQAQ#v=onepage&q=courage in healthcare shibley&f=false

Great ideas. We've been thinking of how best Patient Safety Learning should celebrate the day. Two of our team, @Mike Bird and @Margot, shared suggestions with our Board last week. Who also liked them. I'll leave it to them to share details. Helen

Hi Lorri, I hadn't read that article before. It's brilliant and spot on! Thank you There was an organisation where I eneded up as a 'toxic handler' thought I didn't realise that when i joined. It was the only role that I left without another to go to. After two years, I just couldn't take it anymore! @Claire Cox We defeinitely need to add to the hub