Claire Cox

Hi Tom,  thank you.  I would like to know more about what you are doing - sounds right up my street!

Thanks Jonathan!

The narrative of a datix is so important.  I am new to the patient safety manager role, so I have limited experience in dealing with the 'back end' of datix. From the small amount that I have seen - you get many (tonnes actually) that are no harm, and you can tell that 'I am going to datix you' type reports.  

Datix may not be the best place to report these type of incidents - but where else can you log them?

When reading the narrative you can get a sense of what is going on and the theme of it - communication, frustration with current systems/processes.  These reports should not be ignored as, if looked at and themed with others, tell a powerful story about what is happening in that area.  It may highlight risk hot spots or a poor culture of speaking up in certain areas, it may be an indicator of a deeper problem at play.

Reporting systems are process driven.  What you do with that information is not always process driven.  The serious incidents are a process - but the no harm incidents often don't follow a process, so are often left aside.

These small, seemingly insignificant events with a narrative are important.  

I am not sure what other patient safety managers do , but I am collecting the themes of all no harm events that happen in my directorates and will be looking at them on a monthly basis to spot trends and hotspots.

We have a process to capture incidents.  This is not the problem.  The problem is with what we are doing with the information captured. How we interpret the data, who we involve, how we feed back and how we share actions and how we change practice - this is the hard work.  It is easy to complain about Datix or any other incident reporting system and its functionality - its not so easy to act on the information it is giving us.

As I mention, I am new to this area - 1 month in.  

Naive? Possibly, wanting the best for patients and staff? Definitely

not just patients with COVID..all of them.  It all boils down to strong leadership in times of uncertainty

Great interview Martin, thank you.

I would be interested in how they will manage the waiting list back log.  Are you able to go back to the surgeon and ask this?  

Thanks Eve,  looks like I am in your stage 2 category.  All the positives to look at are great, but what I dont want is praise or grand gestures from our leadership team  What I would like is to feel valued.  

I hear that some Trusts are taking away the wellbeing hubs, the free tea and coffee and free parking.  That to me suggests that they only valued us when they needed all hands on deck.....now not so much.  

Simple steps to value our wellbeing is a start.

Loving the 'Why?' Martin.  In healthcare we get so hung up on the 'How did it happen?' rather tackling the more difficult issues of why it happened in the first place.

Love your blogs, thank you 

Hi danni.  
 

yes we have a walkie talkie held by someone outside the room and a hearing mike (like Madonna wears) inside the room.  That was mmmmm they can communicate together.  Head sets are great with a hood while the hand held is good for the mask. 
 

something like this. https://www.ebay.co.uk/i/322527046245?chn=ps&norover=1&mkevt=1&mkrid=710-134428-41853-0&mkcid=2&itemid=322527046245&targetid=879554672798&device=m&mktype=pla&googleloc=9045161&poi=&campaignid=9441268971&mkgroupid=96107915015&rlsatarget=pla-879554672798&abcId=1139366&merchantid=118933575&gclid=Cj0KCQjw7qn1BRDqARIsAKMbHDZsGmoMFhewp_G9MTh3IB2bLy5fq6UDTcu37NojZHTiwivfTx2lm14aAjXNEALw_wcB

Infection control. 
 

all hearts that come to us stay in quarantine for 72 hours away from clinical areas. 
 

They are kept in the ward office in envelopes ready to be given to the Patient and relatives to ensure minimal touching of the hearts.  
 

Hearts can then be washed in a 60 degree wash at home.  
 

In Brighton, we now have a treatment escalation plan for all patient arriving in our ED.  Since the outbreak of COVID19 we have been able to push this forward to ensure all patients have this important discussion and know what to expect. 

Thank you @Katharine Tylko  I feel odd that people call healthcare workers brave.  I feel we are very well protected by the NHS.  We have job satisfaction, we have security, we have great holiday, pensions......we are not the brave.

The brave are the patients and the families, that have to navigate through healthcare.  

All the more reason to work together

Hi Derek 

I work in the NHS as a nurse.  I am not in any way IT or digital savvy, but I would like to comment.

I visited a US hospital on an exchange last year.  I saw the benefits of using e wristbands in many situations; drug administration, medical notes, treatment requests and communication between teams even down to what type of surgery and the equipment that is needed for that surgery. 

I could see that it solved numerous problems it could solve.

It boils down to money, finding a wristband 'brand' that will fit all of the NHS requirements and needs and most of all the NHS needs to use just the ONE type.  What ever digital system we use it needs to be the same one.  Standardisation is the key, but with multiple budget holders and differing needs among providers we may end up with different types that do not have the same safety standards.

This is a great question for anyone working in NHSX

Hi @Martin Hogan  that has really scared me.  I haven't done agency work, now i have read this, I'm not sure I ever will.  The ward you worked on sounds as if there is a disaster waiting to happen.

As an agency nurse how empowered are you to speak up?  As an agency nurse are you able to use the FTSUG (freedom to speak up guardian) at that Trust if you are not an actual member of that Trust?

I wonder if patients realise the risk that transient staff pose if they haven't had appropriate induction.

Thanks so much for posting..... I look forward to hearing more

Hi @Netty

Patient safety 'investigators' are rarely seen in the clinical areas.  After filing a report myself (numerous times) at no point have I been asked about an incident.  Even if it was a serious one.  The only one I did get asked about was when it went to a coroners court.  

Speaking personally, I would like someone to ask me more about the incident as there is usually so much more to it than just the report.  We usually don't have much time to fill in every detail.

The person filling out the report usually feels strongly that something had gone wrong.  They may even have some solutions?

I know feedback from reports is also an issue.  Often after reporting it goes off into a black hole.  We get an automated message stating it has been logged.  Then nothing.

This feels as if nothing is being done, we don't know the process, we never find out the outcome.  It can discourage from reporting again.

Being visible may be a start to understanding each others role and processes better?

I would like to know how other Trusts deal with feedback from Datix (other reporting systems are available)

What a brilliant idea for the Lary patients - I'm not sure we thought of that! @Emma Richardson that would be great tell all our trachy and lary patients on follow up

Hi @Danielle Haupt! 

Lovely to hear from you.  Thanks for sharing your leaflet - I shall pop it on the main hub so others can find it easily.

Call 4 Concern here in Brighton hit a small problem...… the phone.  The phone signal kept dropping out - so we have invested in a different phone and answer phone messaging service so that we don't miss calls.

@Emma Richardson di a great talk at the senior management board the other day - they loved it!!

It would be great if all hospitals had this service wouldn't it!

Speak soon,

Claire 

Thank you to the Dr that sent this blog in to us, powerful and moving.  
 

What needs to change in order for this care to happen every time.  Not just by chance that a clinician has lived experience?
 

Hi @HelenH   Yes.  I have been in contact with the brilliant @Paul Harris  he will have more information. 

Thank you for the comment @Andrew Ottaway   I saw that the FTSU guardian commented on twitter that the private sector have to have a FTSU guardian if they are  providing NHS care (in this case I don't think they are)  So what happens here?  

I expect people using private healthcare do not realise how unsafe their care could be.  They are paying the price - literally.   Terrifying

Join the discussion around this topic here.....

By posting anonymously speaks volumes to me.  It is a reflection of the fear that is entrenched in speaking up in healthcare.   Fear of putting your head above the parapet and fear of  vilification.

I wonder if their Trust knows that this is even a problem?

Thanks so much @Judy Walker  we use AAR's in out Trust.  I was last part of an AAR when there was an unusual and distressing incident that happened.  All staff involved got together and had an AAR that day to discuss what had happened using the framework.

It isn't just about learning opportunities, its about how we communicate to each other, its about understanding and listening to how others have experienced the event.

Not only did we all see from others perspectives, were were able to talk to each other on the same level.  We had all gone through a very harrowing experience and were able to open up as human beings rather than 'the nurse ', 'the doctor' or 'the healthcare assistant'.  Everyone has a chance to say how it was, the way they experienced it.

After this , it made working with these people again so much more enjoyable and easier.  We had respect for each other and were able to communicate better.

Yes, they can be time consuming.  I truly believe it we didn't have an AAR that day, at least 2 staff members would have gone off sick with stress.  

Investing in staff well-being is crucial.

@Simon Noble-Clarke speak with him...he may be able to help?

Great work Luke.  I wish we had something similar in the Hospital where i work! @Emma Richardson

I would be interested to hear what the hurdles were @Danielle Haupt

Love it @Danielle Haupt  !!