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HelenH

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  1. Content Article Comment
    Hi @Andrew Ottaway and @Claire Cox Thanks for the discussion and update Andrew. I think it would be helpful to clarify responsibilities and I will write next week to the FTSUG's office, the CQC and NHSI. It does appear to be a loophole. Will keep everyone posted. Helen
  2. Content Article Comment
    'Absolutely 100%' - I so admire you for doing the right thing in reporting and having the integrity, compassion and commitment to patient safety to do so again. As the Chief Executive of Patient Safety Learning, wife, daughter and mother, thank you. I hope the support you receive in telling your story will help with the distress and anguish this incident has caused you. Thank you for sharing
  3. Community Post
    It is I agree, a multi faceted set of issues. Really appreciate the honesty and bravery of people who share their experience and perspectives. As a patient I want to ensure that any error and harm is recognised and that I or my family are supported in whatever way I need. I want to know that the organisation providing me with care understands what went wrong and has an appropriate response, whether there are systemic issues that need to be addressed or whether there are support or performance management issues with staff involved. I want such processes to be fair, that there is learning and this is acted upon and that the risk of error and harm is reduced. I want there to be learning from the overall process of investigation, for there to be support (to patients and staff) and that learning is shared for wider improvement. I want staff not to fear making an error (healthcare is complex and we work in systems that often aren't designed or operate effectively for safety) and if they do, they should not be victimised. Any suggestion of deliberate harm or wilful negligence is different and this should be addressed fairly and swiftly. The health care system needs to be accountable for its performance and the safety of the care it provides - this, in my view, is an organisational leadership responsibility that shouldn't be dumped onto individual staff members. We have been engaging with a colleague from a Trust in London about the support they are developing for staff; what has often termed the 'second victim.' Maybe this is now an unfortunate phrase as we better understand what harm is done to families and friends when there is unsafe care. So language aside, we need to support staff to share their experiences and support them to deal with the processes that they will go through and the guilt and self blame they often experience. It is welcome to hear that there are fabulous resources being developed and we are keen to write them up for wider sharing.
  4. Content Article Comment
    Hi @Clive Flashman The link is here
  5. Content Article Comment
    Check out discussion on our community page
  6. Community Post
    Thanks @lzipperer I was just drafting an email to get it on the hub. Super speedy - you beat me to it! Thank you @Clive Flashman and I are in active discusion with @Gary Saunders at NHSX and their CEO Matthew Gould. There is clearly a huge amount of work to do to embed patient safety into this field. NHSX's Mission 4 (of 5) is on Patient Safety. A commendable ambition but, in light of this report, one that is just starting to be scoped. I'm redaing it now and see the need for patient safety issues to be quantified and deisgned into their development programmes. We'd welcome reflections on challenges, risks, opportiunities and insights from elsewhere in healthcare and other industries. Your thoughts will inform our discussions with NHS Thank you in advance. Helen @Andrea D you might be intersted too
  7. Community Post
    Fascinating Alex, thanks for sharing. I'll leave it to more informed experts than me to reflect and comment! @Claire Cox Can we incude within 'Learn' on the hub too so that anyone researching will access this directly? Alex, I've a question about patients and families involvement in handovers and SBAR. Is this an area of research and is there clear policy on this? In th examples you give above, I infer (maybe wrongly!) that the patient and family members were asking questions as this was the only route for them to be communicated with? I've been in that situation myself where my only source of information and opportunity to ask questions was in interupting a 'handover.' I'd welcome your reflections and that of others. @Joanne Hughes Might you have some thoughts too?
  8. Community Post
    Thanks Catherine for using the hub for this enquiry. @PatientSafetyLearning Team Let's use this request to source as many tools and templates as we can!I've sent you through a few templates and reports that include templates to add to the hub. When they're on there can you reply to @Catherine Evans with the links please. @Claire Cox @Mark Hughes Let's tweet the request and use this route too. @cheryl crocker @Ursula Clarke Do the AHSN/PSCs have access to these, any suggestions?
  9. Community Post
    Completely agree with that, Mark. The main challenge may be harnessing these to help draw attention towards the bigger picture and need for changes at a system level
  10. Content Article Comment
    thanks Jane. Great presentations at a great conference
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    Love this. Thanks Jen
  12. Community Post
    A very intersyting question from our conference and especially so in the run up to the general election. NHS Providers CEO, Chris Hopson, has today called on all political parties not to use the NHS as a 'political; waepon.' Politicians have a huge impact in a state funded system - from setting priorities, agreeing funding and clearly setting the culture within which everyone works. I wonder whether there has been formal research undertaken on this? Does anyone know - whether in the UK or internationally? A few initial reflections/comments/questions: - Never events are a concept much loved by politicians and leaders as it shows that they are taking things seriously and and can respond to unsafe care with 'something must be done' investsigations. But does this concept help people's understanding of the complexity of care. And indeed, why are some events 'never' and others not? - Politicians vary in their interest and bravery when it comes to patient safety. Jeremey Hunt commisioned some significant inquiries into unsafe care and organisational failure. Will others do so? - What evidence is there of political committment to implement recommendations from multiple reports and inquiries that affect patient safety? From Bristol Heart, Mid Staff, Morecambe Bay, Liverpool Community and many more...can we say that politicians have driven change and improvement? The All Party Parliamentary Group on Patient Safety hasn't been active for a while now. Post election, aren't these issues ones that they should be addressing? Comments/discusison welcome. @Mark Hughes
  13. Community Post
    HI Emma, good luck with your project. Sounds very valuable and please do share with us on the hub when you've completed it. I attended a great PS conference at the Homerton Hospital last week. One of the projects that they outlined involved a thematic analysis of deteriorating patients. They used the findings to restructure the resources of the clinical team and night cover as well as changing communication, improving team work etc. You might find it valuable to review. @linniepontin is the Quality and Safety lead. Linnie, can you help? Helen
  14. Community Post
    @linniepontin Fabulous day at Homerton yesteday. Thanks for inviting me and giving me insight into the great work that's going on. Stephens' suggestions above could be very helpful for you and as you develop better quality data on patient safety eg 'Ward Assurance results, satisfy yourself that where it is possible, they are outcome orientated rather than just focusing on compliance with a process. Look for ways of 'humanising' the data i.e. use a language that identifies the impact on patients and, importantly, use language throughout that will be understood by patients and the public.' What do you think? Helen
  15. Community Post
    Great stuff. @Clive Flashman will be in touch with you to follow up how we can make this happen. @Jon Holtand @Mary-Jo Patterson can you invite other CCG PS Managers onto this discussion forum and we'll use it to kick off a new communiity
  16. Community Post
    Talking with John Holt, PS Mnager at Birmingham and Solihull CCG today. Would it be helpful to set up a CCG PS Mansger community?
  17. Community Post
    Devina outlines the local intelligence networks that she’s set up as accountable officer for controlled drugs in NHSI NW. Providing ideas and evidence for improving patient safety and support to front line staff in a multi organisation setting
  18. Community Post
    Fabulous presentation by Vikki from North Middlesex and @Ben Tipney The Greatix initiative is fantastic! As is your human factors training programme and the excellent ideas and changes have come directly from it. Would love to have a write up on the hub
  19. Community Post
    Fabulous conference. Please share your take away actions and start a discussion
  20. Content Article Comment
    @Samantha Does this automatically get posted to the community for discussion?
  21. Content Article Comment
    Excellent blog, thanks Adam. You absolutely nail it in that it’s not just about knowledge and skills but behaviours and values. @Lesley W and Lubna and I have been working with colleagues at HEE to try and design this into their competency framework - not just for specialist roles in patient safety but for all leaders. To be honest, we’re not getting much traction. It seems to be more about updating the curriculum. Any suggestions as to how to create more influence?
  22. Content Article Comment
    I found this related resource that might be helpful: https://www.gov.uk/drug-safety-update/paraffin-based-skin-emollients-on-dressings-or-clothing-fire-risk
  23. Content Article Comment
    @Clive Flashman I so agree. I also remember this from NPSA days and am absolutely shocked that reports of theatre fires are still increasing. Well done @Kathy Nabbie for sharing your insights, really helpful resources and the disarming video.
  24. Community Post
    Hi Alison, definitely a discussion for you to contribute to! @alisonleary And Elaine Maxwell too. Helen
  25. Community Post
    @Pete Smith We'd be delighted with that prize! Helen
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