HelenH

Hi @Ben Tipney, the more I learn about effective safety management systems the more I understand how related everything is! I agree that Professionalising Patient Safety is so vital - having specialist knowledge and capacity to support the design of safer systems, analysing data, improving services and safety and evidencing that change from reporting and shared learning. Expecting over-worked clinicians to report incident and near misses when they don't have the time or confidence that anything will happen with the data will make reporting rates per se an unreliable indicator of safety performance. 

And with regard to professionalising patient safety, I don't think we have standardised role descriptions, competency frameworks and person specifications for patient safety roles. Or do we? Does anyone know whether these have been developed and if so where these might be? 

Just now, HelenH said:

Hi all, I had a great meeting with @Neal Jones yesterday and in a wide ranging discussion we reflected on design and human factors. I recall some great work many years ago on the redesign of ambulances (that the NPSA contributed to) and wondered what happened to that initative and whether this had developed into designing new hospitals for patient safety. @Neal Jones recalled the DOME (designing out medical error) project http://www.domeproject.org.uk/index.html. This web site is dated 2010 and it seems to have been a three year funded project. Is this innovative approach still 'live?' Does anyone know of any work on human factors in hospital design to deliver safer care (processes, equipment, layout, technology etc)? In the UK or internationally?

By googling I've found articles on specific departmental inititaives and people calling for more to be done but not much of the 'how' or any requirment to embed patient safety into new build hospital deisgn. Surely there must be soemthing?!!

Hi all, I had a great meeting with @Neal Jones yesterday and in a wide ranging discussion we reflected on design and human factors. I recall some great work many years ago on the redesign of ambulances (that the NPSA contributed to) and wondered what happened to that initative and whether this had developed into designing new hospitals for patient safety. @Neal Jones recalled the DOME (designing out medical error) project http://www.domeproject.org.uk/index.html. This web site is dated 2010 and it seems to have been a three year funded project. Is this innovative approach still 'live?' Does anyone know of any work on human factors in hospital design to deliver safer care (processes, equipment, layout, technology etc)? In the UK or internationally?

By googling I've found articles on specific departmental inititaives and people calling for more to be done but not much of the 'how' or any requirment to embed patient safety into new build hospital deisgn. Surely there must be soemthing?!!

I once raised with a very senior leader that our approach to managing complaints wasn't leading to learning or action to improve care. I was admonished and clearly told (the words are embedded in my brain) that 'we are managing complaints not doing patient safety.' At that point I knew I had to leave the organisation and that despite best endeavours, a resistant and closed-minded leader would not deliver the change that was written in the organisational strategy. On the scale of courage, it's pretty low compared to clinicians who whistleblow but it had a profound effect on me. From that day onwards I was effectively hounded out of the organisation for challenging 'the system.' Things worked out in the end but it was an interesting change in career that I hadn't planned.

How much worse it must be when raising concerns/making suggestions for improvement with your employer challenges your job, future career and livelihood.

I wonder how many staff would 'speak up' and share their views if they felt safe to do so and confident that their insights would listened to and acted upon. 1% of staff, 5%, 20%, more? What do people think?

@alisonleary brought to our attention a recently published book 'Courage in Health Care: A Necessary Virtue or a  Warning Sign.'

https://www.pslhub.org/learn/miscellaneous/suggested-resources/recommended-books-and-literature/courage-in-healthcare-a-necessary-virtue-or-warning-sign-by-shibley-rahman-and-rebecca-myers-r750/

Great ideas.

We've been thinking of how best Patient Safety Learning should celebrate the day. Two of our team, @Mike Bird and @Margot, shared suggestions with our Board last week. Who also liked them. I'll leave it to them to share details.

Helen

Hi Lorri, I hadn't read that article before. It's brilliant and spot on! Thank you

There was an organisation where I eneded up as a 'toxic handler' thought I didn't realise that when i joined. It was the only role that I left without another to go to. After two years, I just couldn't take it anymore!

@Claire Cox We defeinitely need to add to the hub

Me neither @Andrew Ottaway. That's shocking

@Claire Cox I wonder whether we should tweet this as well and ask for contributions? If we are truly to work as a integrated health and care system, then having different protections and support systems just doesn't feel right

Hi Jayne,

Great to hear that you've been welcomed and supported.

We agree that more 'how to resources' are needed. We are aiming to collate a repository for these and to contribute with our own ideas. Anyone out there that can help? Annie, I remember when we met last year that you showed me some fabulous governance frameworks, policies and resources that you'd developed at Barts. Can you share some? @Annie Hunningher

Also, I'm meeting with Neal Jones at Broadgreen and Liverpool Trust in a few weeks time to capture his insights and experience. They're doing amazing work there too..

Anyone else?

Helen

Hi Jayne, Great to hear. Any chance you could share an outline of your induction so that others could use this to design theirs? Happy to have it anonymised if that's an issue. Thanks Helen

Hi Dani,

Yes, you're in the right place. We're at beta (tech speak for starting out and wanting feedback) and great posts like yours will really help kick off conversations and sharing knowledge.

I don't have detailed knowledge of your service and this initiative (I'm not a clinician) but at Patient Safety Learning we are going to be developing with colleagues (from the World Heath Organisation) an implementation guide for safer care - how to implement and spread great ideas like yours - helping with how identify opportunities and provide ideas to overcome barriers. This won't help you in the short term (sorry) but we could build on your insight in shaping our work. We'll be starting this work in the next month or two. Would you be okay if we contacted you directly when we do?

Love to hear any other's contributions and resources.

Thanks again for posting, Helen 

Hi Neil, great that you've joined the hub and I look forward to your contribution. And that of your members too? Sharing knowledge for improving patient safety is a MUST!

Hi Claire, I think it would be helpful to capture good practice on the set up and operation of Safety, Risk and Quality teams - key roles, strategies and plans. I've just met with Moira Durbridge this morning, Director of Patient Safety and Risk at United Hospitals Leicester. They are doing amazing work and she's going to share a ton of resources that will be really valuable.

Let's set up a resource library on the hub for this.

A key part of professionalising patient safety as we outline in our Blueprint for Action https://www.patientsafetylearning.org/resources/blueprint

Hi Claire, at the Health Care Plus conference last week, when I asked the audience at a couple of sessions, some staff did say they reported near misses and were confident they would be acted upon. I didn't get a chance to follow up with them, sadly. Would be good to get more insight into 'the how.' Thoughts anyone?

 I met at a recent conference a newly appointed Patient Safety Manager. She’d been working in a supporting role in another organisation and was delighted with her obviously well deserved promotion to a more senior role of patient safety manager in another Trust. But 6 days in, she’s had no induction, there is no patient safety strategy or plan in the Trust, there isn’t any guidance as how she should do her job other than just ‘get on with doing RCAs. ‘ She doesn’t know who she can turn to for advice or support either in her Trust or elsewhere. Are there networks of PSMs she can turn to? Surely there is a model framework for patient safety that is produced as a guide? How can we help her and other PSMs?

We know that blame and fear is toxic. It makes working in healthcare unsafe for staff and is a huge barrier to patient safety - staff won’t share what goes wrong if they expect not to be listened to or worse, will be criticised or blamed for errors that are really attributable to unsafe systems. It would be really valuable to better understand how this feels and the impact it has on clinicians and the safety of patients and service users. 

We know from academic research that patient engagement reduces the risk of unsafe care and harm, in patients own care and improving safety for all. Some organisations are investing time (if not money!) in recruiting, training and supporting patient leaders to work with Executives and senior staff, sharing their experience and as they engage with staff and patients, report back what they see. The model in Berkshire, as shared with me by Douglas Findlay, patient leader, is that they don’t make decisions on what needs to change and how, but report back what they see for others to  learn and act. Do we know of other models of good practice? What can we learn and share from them?

How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?