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HelenH

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Everything posted by HelenH

  1. 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
  2. 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.
  3. 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
  4. 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
  5. Community Post
    Don't forget to promote on the hub 'events' - a great initiative that needs to spread
  6. 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
  7. 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
  8. 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
  9. 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
  10. Community Post
    @Claire Cox Hi Claire, can you coordinate with Carol to help Louise please. Thx
  11. 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 [email protected] to follow up?
  12. 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?
  13. 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
  14. 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
  15. 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.
  16. 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.
  17. 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
  18. 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
  19. 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.
  20. 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
  21. 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?
  22. 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?
  23. 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
  24. Content Article Comment
    thanks Jane. Great presentations at a great conference
  25. Content Article Comment
    Love this. Thanks Jen

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