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HelenH
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Content Article Comment
Looking after each other in times of change
HelenH commented on Sally Howard's article in Blogs
- Staff support
- Teamwork
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(and 3 more)
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One of the most powerful responses I’ve heard to the pandemic. Wonderful insight and advice. Thank you, Sally. I’m going to share widely. Helen- Posted
- 2 comments
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- Staff support
- Teamwork
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Community Post
Thanks David. I’ve promoted on my FB and LinkedIn accounts too. Hope you’re well and safe. Helen- Posted
- 11 replies
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Community Post
Covid-19 safety of GP practices
HelenH replied to Katharine Tylko's topic in Coronavirus (COVID-19)
- Infection control
- Staff safety
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(and 3 more)
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Think I’d do the same! Need a clinician’s input here @Claire Cox what do you think?- Posted
- 4 replies
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- Infection control
- Staff safety
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Content Article Comment
COVID-19: what are you wearing? Working in a soup of droplets
HelenH commented on Patient Safety Learning's article in Blogs
- Virus
- Staff safety
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Well said Kathy. Some of this is resourcing but much of this is prioritisation that doesn’t put patient and staff safety as a core purpose. Lessons must be learned- Posted
- 5 comments
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- Virus
- Staff safety
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Content Article Comment
COVID-19: what are you wearing? Working in a soup of droplets
HelenH commented on Patient Safety Learning's article in Blogs
- Virus
- Staff safety
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‘There are not any showers for nurses at work.’ Outrageous. We have to care for staff. No staff safety, no patient safety- Posted
- 5 comments
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- Virus
- Staff safety
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Content Article Comment
World at war: The journey continues
HelenH commented on Carol Menashy's article in Blogs
- Medicine - Infectious disease
- Mental health
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Great that Royal Free have recognised the necessity of supporting staff at this very difficult time. Wondeful that your skills, energey and compassion are being released to support this. Please do keep us in touch with insights into how its all going. I'm sure there's valuable learning that others can benefit from. Best wishes, Helen- Posted
- 1 comment
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- Medicine - Infectious disease
- Mental health
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Article Comment
Child deaths 'not properly investigated' at top hospital
HelenH commented on Patient Safety Learning's news article in News
- Patient death
- Organisational culture
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(and 1 more)
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I worry that the new NHSI PS incident framework allows organisations to chose whether they investigate or not. Those with poor safety cultures could chose to avoid proper investigation. No learning and no action will inevitably lead to further harm @Joanne Hughes- Posted
- 2 comments
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- Patient death
- Organisational culture
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Community Post
The Patient Safety Incident Response Framework
HelenH replied to Jon Holt's topic in Investigations, risk management and legal issues
- Near miss
- Never event
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There is much that is well intentioned in this framework. I think there is much that will not achieve the aims and may result in serious unintended consequences. I'm drafting a blog to kick off discussion.- Posted
- 10 replies
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- Near miss
- Never event
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Content Article Comment
We are missing the potential of patient feedback (March 2020)
HelenH commented on Claire Cox's article in How to engage for patient safety
- Feedback
- System safety
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(and 3 more)
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James says 'If our understanding of, and our systems for, patient feedback are limited to seeing it simply as data, concerns, compliments, or even stories, then I think we are missing this bigger picture. Feedback is a relationship. It is one way that people receiving a service can express their care, in return, for those who provide it, and for others who will use it. It is an expression of the values of equality and mutuality which lie at the heart of our health service. Our current approaches to patient feedback recognise little of this – and it is time they did.' Absolutely. Completely agree- Posted
- 1 comment
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- Feedback
- System safety
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Content Article Comment
When to investigate? Part 5. A series of blogs from Dr Martin Langham
HelenH commented on MartinL's article in Why investigate? Blog series
- Investigation
- Patient safety incident
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Brilliant as ever @MartinL I learn so much from your insights and advice. I wonder whether the NHSI Patient Safety Incident Response Framework will reflect this wisdom? https://improvement.nhs.uk/resources/future-of-patient-safety-investigation/- Posted
- 2 comments
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- Investigation
- Patient safety incident
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Community Post
Mental health patients - when there's no place of safety
HelenH replied to Patient Safety Learning's topic in Safeguarding
Interesting there’s a bbc 3 and bbc 2 programme on SW London MH Trust tonight- Posted
- 3 replies
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Content Article Comment
Silent witness – My experience when filing an incident report
HelenH commented on an article in Florence in the Machine
- Organisational learning
- Investigation
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Thank you. 'it is up to the investigator/team to establish the facts including obtaining information from those involved' Absolutely. One of the challenges that we hear is whether such people/teams have the capacity to respond as you outline. Commitment and knowledge does need to be matched with sufficient resources to investigate, learn and then take action. Any insights that you have of good practice, we'd love to hear from you - in a blog or sharing policies, SOPs, guidance etc. Helen- Posted
- 8 comments
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- Organisational learning
- Investigation
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Content Article Comment
Silent witness – My experience when filing an incident report
HelenH commented on an article in Florence in the Machine
- Organisational learning
- Investigation
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I think collectively that many have forgotten that reporting is about learning and taking action to prevent errors and harm. It’s not an activity my it’s own right! It’s also part of caring for and an accountability to staff, saying that we your concerns matter and we’re going to take them seriously. Danielle, I love your suggestions. We’re going to be collating examples of great practice to share and we’ll start with these! If you’ve more detailed information or would write a blog on what you do and the impact it has, that would be wonderful. [email protected]- Posted
- 8 comments
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- Organisational learning
- Investigation
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Community Post
Do not attempt cardio pulmonary resuscitation (DNACPR) - confusion
HelenH replied to Claire Cox's topic in Legal matters
Hi Claire, this must have been awful for everyone. Is this a legal requirement, that a consultant must sign a form?- Posted
- 4 replies
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Content Article Comment
Human factors – the scientific study of man in her built environment. Part 4 of the ‘why investigate’ series
HelenH commented on MartinL's article in Why investigate? Blog series
- Investigation
- Human error
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I've just re-read. Too good a series just to read once. My favourite quote on this one is 'Scheduling 12-hour days – well it keeps investigators in work.' Sadly, I think 12 hour shifts are becoming the norm in healthcare. And that excludes the journey to and from work.- Posted
- 2 comments
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- Investigation
- Human error
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Content Article Comment
My thoughts on the Paterson Inquiry: a blog from a scrub theatre nurse
HelenH commented on an article in By health and care staff
- Leadership
- Culture of fear
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Thank you again for your insight, commitment and bravery. Good questions for Boards., leaders, CQC and Healthwatch to ask too: "Are staff allowed to Speak Up and report safety incidents?" "Are the reports followed up and lessons shared without victimising the person who reported it?" Staff should be allowed for sure. But ideally they should be encouraged and welcomed. Helen- Posted
- 2 comments
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- Leadership
- Culture of fear
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Content Article Comment
Interview with Sue Harris: the UK's first harms prevention nurse consultant
HelenH commented on PatientSafetyLearning Team's article in Nurses
- Patient safety / risk management leads
- Nurse
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Thanks for your insights Sue. Congratulations and good luck with the role. Will be great for there to be more of you! Please keep in touch as the role develops, we'd love to hear your journey and reflections for others to learn from. Helen- Posted
- 1 comment
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- Patient safety / risk management leads
- Nurse
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Content Article Comment
Hi David, a very good point. And a general one about the role of NHSI with regard to patient safety and incident reporting. NHSI is leading on replacing the now outdated NRLS. How will this inform learning and action? Will all risks reported be analyses and transparently reported. Will this be accompanied by the insight from Trusts that have responded with improvement action and advice for others #share4safety What do people think? @Clive Flashman- Posted
- 4 comments
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- Organisation / service factors
- Flawed processes
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Community Post
National Patient Safety Syllabus
HelenH replied to Jon Holt's topic in Professionalising patient safety
Hi Jon, thanks for kicking this off. We’re going to be sharing a blog on this shortly and to help inform discussions. I met briefly with the Academy of Medical Royal Colleges on this yesterday so have some insight to contribute. Btw the consultation response is limited to 500 characters as they want themes not detailed comments. Personally I don’t think this is appropriate stakeholder engagement and consultation on such a vital contribute to patient safety. Patient Safety Learning will update and tweet soon. @Sue Hignett Definitely one for you to review Helen -
Content Article Comment
Human factors – the scientific study of man in her built environment. Part 4 of the ‘why investigate’ series
HelenH commented on MartinL's article in Why investigate? Blog series
- Investigation
- Human error
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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.- Posted
- 2 comments
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- Investigation
- Human error
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Community Post
The Patient Safety Incident Response Framework
HelenH replied to Jon Holt's topic in Investigations, risk management and legal issues
- Near miss
- Never event
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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- Posted
- 10 replies
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- Near miss
- Never event
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Article Comment
Toddlers died after NHS 111 helpline said they were not in danger
HelenH commented on Patient Safety Learning's news article in News
- Skills gap
- System safety
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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!- Posted
- 2 comments
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- Skills gap
- System safety
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Content Article Comment
My experience of speaking up as a healthcare assistant in a care home
HelenH commented on an article in By health and care staff
- Care home
- Care home staff
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(and 4 more)
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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- Posted
- 4 comments
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- Care home
- Care home staff
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Content Article Comment
The SPA experience: NHS Wales Award winner 2016
HelenH commented on Claire Cox's article in Learning disabilities
- Learning disabilities
- Surgery - General
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Brilliant initiative. @Claire Cox are there more resources from this Centre we could add to the hub?- Posted
- 2 comments
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- Learning disabilities
- Surgery - General
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Community Post
National Safety Standards for Invasive Procedures
HelenH replied to Annie Hunningher's topic in Surgery
- Pre-op period
- Intra operative
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@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- Posted
- 1 reply
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- Pre-op period
- Intra operative
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