HelenH

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

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

@Claire Cox Hi Claire, can you coordinate with Carol to help Louise please. Thx

Dear hub members

We've a request to help from New South Wales.  They and their RLDatix colleagues request:

The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions.  Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out  …

Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads?

We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including:

• UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of
• A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors 
• UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020)
• Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations
• Patient engagement in investigations 
• Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations
• Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL

Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/

Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest.

Thank you all, Helen

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. 

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

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?

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?

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

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

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

@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

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

Talking with John Holt, PS Mnager at Birmingham and Solihull CCG today. Would it be helpful to set up a CCG PS Mansger community?

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 

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

Fabulous conference. Please share your take away actions and start a discussion

Hi Alison, definitely a discussion for you to contribute to! @alisonleary And Elaine Maxwell too.

Helen

@Pete Smith We'd be delighted with that prize!

Helen

Hello Aine

Welcome to the hub. Fantatic that you're on it and great to connect again. You'll have seen the resources in Learn, I know https://www.pslhub.org/learn/patient-engagement/

We're looking forward to meeting up with your collegue, Ray Power, tomorrow at our conference. We'll get him regsistered on the hub too!

Helen

Hello Jaoine, thank you so much for your post and support. A really good question although I don’t personally know the answer. But let’s hope someone can help you through the hub. I wonder whether Laurie can help you? @Laurence Goldberg FRPharmS

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?