HelenH

Thank you Martin, much rich insight here. NHS Improvement is developing a new Serious Incident Framework. I do hope that this work reflects on: 'HFs in the first sense is a study of basic processes. Investigations are always about these basic processes – seldom about how someone felt about someone else and about how these senses interacted with the environment, the equipment and the system or method of working.' There is criticism that current approaches to investigation prioritise 'process over outcome.' Let's hope that changes soon.

Hi Jon I've heard directly from Aidan that there won't be an implementation plan as such for the NHSI PS strategy, they're just getting on with it. Aidan says they are reporting back through the National Quality Board. I met with Ted Baker this morning from CQC, he jointly chairs the NQB. I said there were a lot of interested people in the service (clinicians, ps and risk managers in providers and commissioners) who want to know what the NHSI PS strategy implementation means for them and in particular the incident framework. I'd also heard at a meeting with @Amelia from Browne Jackson that the framework will be released to pilot sites only at this stage and only wider after pilot evaluation. Would love to know more if anyone else has any insights to share. Thanks for raising Jon, sorry I can't help more with the answers. Helen

Sadly, there does not appear to be an effective systems for sharing learning from coroner's reports - either to prevent the risks of harm being repeated or indeed sharing the good practice that is developed in responding to these reports. We're writing to the Chief Coroner about this so watch this space!

Dear anonymous HCA, Thank you for sharing your experience with us. What a shocking and distressing account; both for the residents of the home and for yourself. Would you be willing to speak with the CQC? Colleagues there have already been very responsive to another whistle blower who contacted us. I'm sure that the CQC would be keen to know the details of the home so that they can follow up. Here are links to CQC's site should you or anyone else want to report poor care. https://www.cqc.org.uk/contact-us/report-concern/report-concern-if-you-are-member-staffhttps://www.cqc.org.uk/give-feedback-on-care It may be that there is a professional regulation concern. The NMC state that 'they exist to enable better and safer care. One of the ways we do this is by acting when someone tells us they have a concern about a nurse, midwife or nursing associate which could put the safety of patients at risk, or damage the public’s confidence in the nursing or midwifery professions.' ...... and that 'If you feel uncomfortable about contacting the employer, or you don't know who the employer is, or it seems as though the public might be at risk, then we would encourage you to go ahead and make the referral to us.' https://www.nmc.org.uk/concerns-nurses-midwives/concerns-complaints-and-referrals/making-a-referral-to-us/ I hope that's helpful. With very best wishes, Helen

Brilliant initiative. @Claire Cox are there more resources from this Centre we could add to the hub?

@Annie Hunningher this is excellent, thank you so much for sharing. @PatientSafetyLearning Team let's add this to the Learn section of the hub and tweet it. This is Bart's Local Safety Standards for Invasive Procedures (LocSSIPs) - these are minimum standards based on best practice that apply to all staff and all services. They include 8 sequential steps that are reinforced with clear organisational standards. Let's get everyone to share their standards. @Annie Hunningher at the excellent recent session with the UCLP AHSN, you outlined the peer review process that you've been developing to assess and provide feedback on performance. Anything that you can share with us on this? Either the aims, the peer review process that you're developing and progress/commitment/barriers/opportunities or indeed the guidance for peer reviewers that is being drafted. Helen

There are huge communications issues in an industry as complex as healthcare: and as @Steph O'Donohueand @Claire Cox point out, these can have a serious impact on service delivery. Worse, poor communication can result in unsafe care whether: within and between disciplinary teams between clinicians and patients between patients and carers between managers and clinicians And that's communication that is verbal, non-verbal, written, electronic. And whether in diagnosis, consent, handover, escalation, medication management etc In your example Steph, I'm not sure how easy it is for clinicians to hear themselves. Maybe ask a patient! When I worked at the Alzheimer's Society, we had groups of service user volunteers who would review written communication for the NHS, Local Authority and other service providers. They were brilliant and they simplified and clarified so many leaflets, advice and guidance notes, official forms etc. I think, if we don't already have this on there, that we should have a section on communication and patient safety on the hub. And highlight some great resources: see below Much work by prof. dr. annegret hannawa, professor of health communication - interested in the conceptual and empirical intersections between human fallibility, interpersonal communication science and healthcare. https://annegrethannawa.com/ https://bmjopenquality.bmj.com/content/8/3/e000742 https://improvement.nhs.uk/resources/improving-safety-critical-spoken-communication/ https://www.researchgate.net/profile/Douglas_Brock/publication/257838524_Interprofessional_education_in_team_communication_Working_together_to_improve_patient_safety/links/00b7d52cad52c4ff23000000.pdf https://www.sciencedirect.com/science/article/abs/pii/S0012369208601610 https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf https://www.nursingtimes.net/clinical-archive/patient-safety/tools-and-techniques-to-improve-teamwork-and-avoid-patient-harm-12-12-2016/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4134163/ https://patientengagementhit.com/news/patient-provider-communication-strategy-may-boost-education https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/TeachBack-QuickStartGuide.pdf etc etc Helen

Thanks @Peter Walsh. And that accountability is also organisational. A just and learning culture means that organisations learn from unsafe care and good practice, taking action to reduce the risk of future harm. And to share that learning, widely.

A very valuable comment, thanks Eve. Some questions: How are others responding to the challenge of setting and monitoring safe staffing levels? How is the acuity and dependency of patients assessed at ward/operational level across all care sectors? Let's encourage people to share their perspectives; challenges and how they are developing approaches @alisonleary And a research and academic perspective would be invaluable. @Mark Hughes Let's post a distillation of Eve's comments and these questions on social media and encourage responses and on the hub Helen

What is Civility Saves Lives? 'We are a collective voice for the importance of respect, professional courtesy and valuing each other. We aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours.' @Patient safety Hub If you go on the site, they reference in their tweets quite a lot of resources including videos. Would be great to get these all on the hub

Don't forget to promote on the hub 'events' - a great initiative that needs to spread

Hi @Sophie Caswell Now that's an interesting question! I'm assuming that you're raising the issue where you would expect there to be written consent? Clearly there are circumstances where verbal consent is appropriate. Maybe you're highlighting where there is a conflict in the views of the patient and the organisation as to whether there was consent at all? This might be of interest to @Joanna Lloyd and @Amelia as they are lawyers and might be able to direct you to advice, case law etc Helen

'Even with mistakes much more consequential than an airplane meal, many or most people just want to hear someone take responsibility and offer a sincere apology.' True

Hello @Blodwen It sounds a ghastly experience. Thank you for sharing with us. We're going to be publishing something very soon on the impact that unsafe care has for patients and their families - not just when harm occurs but the aftermath, both physical and psychological impact. Best wishes, Helen

Fabulous feedback, thanks. @lzipperer I think the PSNet articles are great, especially the RCA gone wrong. There seems to be much criticism of RCA as a tool that doesn't reflect the organisations and cultural context within which its applied. @Keith Bates Looking forward to hearing more of the investigation and training model. We'll be delighted to post to the hub when you're ready @Ed Marsden 'Chris Brougham & I would be happy to discuss our experience building some new technology to support incident investigation.' Yes please! Can you write a blog for us? The thinking behind your eva investigation tool, I'm thinking