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HelenH

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  1. Content Article Comment
    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
  2. 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 NHSI is leading on replacing the now outdated NRLS.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
  3. Community Post
    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
  4. Content Article Comment
    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.
  5. Community Post
    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
  6. Article Comment
    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!
  7. Content Article Comment
    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
  8. Content Article Comment
    Brilliant initiative. @Claire Cox are there more resources from this Centre we could add to the hub?
  9. Community Post
    @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
  10. Community Post
    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
  11. Community Post
    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.
  12. Community Post
    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
  13. Community Post
    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
  14. Community Post
    Don't forget to promote on the hub 'events' - a great initiative that needs to spread
  15. Community Post
    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
  16. Content Article Comment
    '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
  17. Community Post
    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
  18. Community Post
    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
  19. Community Post
    @Claire Cox Hi Claire, can you coordinate with Carol to help Louise please. Thx
  20. Content Article Comment
    Great article Kathy. Would like to know more about the petition and whether this should call for more research too. Let's discuss with @Claire Cox and @Mark Hughesand how we can promote through a discussion on the hub community. We can link to social media to get wider attention to this issue. Can you email me at helen@patientsafetylearning.org to follow up?
  21. Content Article Comment
    That's great to hear @Aston02. Disappointing that you had to use the service but shows why it's needed. Shocked that senior management behaved that way. Was there any follow up with them do you know?
  22. Content Article Comment
    Great post, thank you to East Kent and congratulations on your award. Will be really helpful to keep informed of your progress and the impact that engaging with energetic and committed Ward Managers will have. Helen
  23. Community Post
    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
  24. Content Article Comment
    Thank you so much for your story. It’s heartening to hear the support you received in what was a difficult tome for you, other staff and especially the family. Does your organisation have guidance/resources that we could share? It would be wonderful if everyone, patients and staff, could have the same experience.
  25. Content Article Comment
    Does also show the contractual vulnerabilities of bank and locum staff in raising issues. Staff shouldn't have to chose between doing the right thing, their professional responsibilities and their livelihood. I'll write to the GMC, NMC and HCPC on this issue. Thanks again to the brave reporter.
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