Claire Cox

Pressure ulcers within the intensive care unit (ICU) have long been recognised as a persistent and complex patient safety issue. Critically ill patients are particularly vulnerable due to immobility, compromised perfusion (the process of blood delivery to the tissues), nutritional deficits and the presence of invasive medical devices.[1] Despite the implementation of prevention protocols, pressure ulcers continue to occur, suggesting that the problem extends beyond individual clinical actions and into the broader healthcare system.[2] Recent UK-based studies have reinforced this view. For example, a national prevalence study found that pressure ulcers remain common in critical care, with medical device-related injuries accounting for a significant proportion.[3] Similarly, Health Innovation East highlighted the variability in outcomes across NHS settings, underscoring the need for system-wide approaches tailored to local contexts.[4] In this blog, Patient Safety Learning's Associate Director Claire Cox shares how she adopted a systems approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model to review pressure ulcers. Before initiating this review, I recognised that pressure ulcers in the ICU were not solely a clinical concern—they reflected broader systemic issues. Patients in intensive care are critically unwell, frequently immobile and often unable to reposition themselves. Their skin integrity is compromised by factors such as impaired circulation, nutritional deficits and the presence of medical devices. Staff operate under considerable pressure, balancing urgent, life-saving interventions with preventative care. Routine practices, such as repositioning and skin assessments, must be prioritised alongside emergencies. Documentation is fragmented—split between paper and electronic systems—resulting in communication challenges and planning inconsistencies. Access to pressure-relieving equipment varies, and escalation pathways are not always clearly defined. These challenges are not attributable to individuals. Rather, they are indicative of a system that does not consistently enable safe care. For this reason, I adopted a systems approach to explore how environmental conditions, tools, tasks and organisational structures interact—and where they may be misaligned. The aim was to move beyond attributing fault and instead identify the conditions that increase the likelihood of harm and how these might be addressed. Applying the SEIPS framework To guide this review, I used the SEIPS model. SEIPS is a human factors framework that examines how components of a work system—people, tasks, tools and technology, physical environment, and organisational conditions—affect processes and outcomes in healthcare.[5] It supports a holistic understanding of safety by focusing on system design rather than individual performance. Step 1: Framing the review I began by clarifying the scope and purpose. The objective was to examine the gap between 'work as imagined' (WAI)—the protocols and guidelines—and 'work as done' (WAD)—the realities of clinical practice. This approach enabled a deeper understanding of how pressure ulcer prevention is enacted in the ICU. A thematic review methodology was also selected to synthesise insights from multiple sources: patient safety incident reports staff interviews and informal conversations observations of workflow and environmental factors. Step 2: Gathering insights I spent time in the ICU, observing care delivery and engaging with staff across disciplines. I listened for patterns, inconsistencies and adaptations—those moments where staff had to improvise or navigate ambiguous systems. Documentation practices were reviewed, with attention to the coexistence of paper and digital records and the implications for communication and care planning. I examined how pressure ulcer risk was assessed, how referrals to tissue viability nurses were managed, and how equipment was accessed and escalated. Step 3: Mapping the system Using the SEIPS framework, I mapped the key components of the ICU system: People: Skilled, responsive staff working under pressure. Tasks: Complex care routines with competing demands. Tools and technology: Mixed documentation systems and variable equipment availability. Environment: A newly established ICU with evolving workflows. Organisation: Gaps in escalation protocols and support structures. This mapping revealed areas of misalignment—where expectations diverged from practice, and where staff were compensating for systemic limitations. Step 4: Synthesising findings The analysis highlighted several interconnected challenges: Absence of standardised risk assessment and escalation guidance. Delays in accessing specialist mattresses. Inconsistent documentation and communication pathways. Limited visibility and support from tissue viability teams. These issues were not isolated; they reflected broader systemic vulnerabilities and opportunities for improvement. Step 5: Developing recommendations Based on these insights, I proposed a series of actionable recommendations: Standardise surface provision and mattress escalation protocols. Enhance visual guidance for managing pressure damage. Streamline access to advanced support surfaces. Strengthen tissue viability support and referral pathways. Clarify documentation expectations and risk assessment procedures. Step 6: Sharing and reflecting The findings were shared with ICU staff and senior leadership. Feedback was overwhelmingly positive—staff felt their experiences were acknowledged and leaders appreciated the systemic perspective. The review contributed to averting a Regulation 28 notice (Prevention of Future Deaths report) and sparked interest in applying systems-thinking more broadly. Throughout the process, I remained grounded in curiosity. I did not begin with assumptions; instead, I asked, observed and listened. This mindset was instrumental in uncovering meaningful insights and fostering constructive dialogue. References European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers.. 2019. Jackson D, Durrant L, Walthall H. et al. Pain associated with pressure injury: A qualitative study of community-based, home-dwelling individuals. J Advanced Nursing, 2017; 73(12): 3061-9. Rubulotto F, Brett S, Boulanger C, et al. Prevalence of skin pressure injury in critical care patients in the UK. BMJ Open, 2022  ;12: e057010. doi:10.1136/bmjopen-2021-057010. Parkinson E, Leming S, Elmore N, Martin S. NHS Wound Care: Rapid evidence scoping review. Health Innovation East, April 2024 Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system design for patient safety: the SEIPS model. BMJ Quality & Safety 2006. Related reading on the hub: Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin PSIRF planning – Pressure ulcer example scenario Application of SEIPS and AcciMap to a patient safety incident Patient Safety: Emerging Applications of Safety Science SEIPS in action

In this blog, Claire Cox, Patient Safety Learning’s Associate Director, talks about the opportunities to improve patient safety and the risks associated with the use of barcode technology in healthcare. As a nurse working in the NHS for over 25 years, I’ve seen first hand how technology has transformed patient care. One of the biggest changes in recent years has been the introduction of electronic scanning. We scan patient wristbands, which are printed with unique barcodes, for many reasons: Patient identification: ensuring that treatments, procedures and diagnostics (such as blood tests, X-rays and scans) are matched to the correct patient. Medication administration: ensuring the right patient receives the correct drug at the correct time. Theatre and surgery safety checks: confirming a patient’s identity before they undergo surgery, reducing the risk of wrong-site or wrong-patient procedures. Blood transfusion safety: ensuring the right blood type is matched to the correct patient to prevent transfusion errors. Specimen labelling: avoiding mix-ups in laboratory samples by linking them directly to the patients' records. Tracking patient movement: monitoring patient transfers between departments, which helps with bed management and continuity of care. In theory, it’s a fantastic safety net. However, in practice it’s not always that simple. If we take scanning for medication as an example, the idea behind barcode scanning is brilliant. We scan the patient’s wristband, scan the medication and the system cross-checks everything to flag up any prescription issues, the correct patient weight, allergies, previous doses, interactions with other medication and of course… the correct patient. It’s meant to reduce medication mistakes and improve efficiency. And when it works, it does just that. But ask any nurse on a busy ward and they’ll tell you about the times it doesn’t go so smoothly. This blog will uncover some of the ‘workarounds’ we are using to enable us to do our job when the ‘system’ lets us down. What are the challenges? Technical glitches and system downtime One of the most frustrating issues is when the scanner simply refuses to work. Maybe the barcode on the medication is damaged or the scanner won’t read the patient’s wristband. This means wasted time trying to troubleshoot or calling IT for support. If the entire system goes down (which happens more often than I’d like), we have to revert to manual documentation. This not only slows us down but also increases the risks of getting it wrong—the wrong patient, wrong drug, wrong time, wrong dose, exactly what the system was designed to prevent. With the increase of patients being placed in non-clinical areas and corridors (what NHS England describes as ‘temporary escalation spaces’), you find that internet access is not always readily available in these spaces and there is Wi-Fi dead spots. The wristbands and the blood labels are generated by us and then sent to mini printers that print and dispense wrist bands; we have hundreds within our trust. The printers often require software updates, usually at different times. As a nurse I don’t know how to update these printers—so they end up not working. The point of escalation in these instances would be to call the IT team. However, the last time I did this I was in a queue for over 30 minutes. I haven’t the time for that, neither has our ward clerk. So, in the meantime the printer remains unusable and we revert to workaround measures. Issue Workaround Risk Wi-Fi dead spot. Override option on scanner. Able to give incorrect drug to incorrect patient—no alerts will be visible Printer not working—due an update. Print out at a different printer. Risk of picking up a different blood label, wrist band—as this may be the only printer working on the ward. Patients may get mixed up, given the wrong drug, wrong blood in tube, etc. Whole system down. Revert to written wrist bands and blood labels. Transcription issues. Workflow disruptions and delays With so many competing priorities, it’s a race to get everything done when you are working on a busy ward. Scanning every medication and waiting for the system to verify it can slow us down significantly, especially when caring for multiple patients. The process may be safer in theory but, when you’re juggling urgent patient needs, these extra steps can feel like a hurdle rather than a help. We should be scanning each patient individually, then going to the electronic drug cupboard to collect the medication. However, when every nurse on the ward is doing the same thing, a queue forms. You could be in that queue for 30 minutes or more. Once you have waited your turn—you scan the patient again, administer the medication, then start again for the next patient. We can be caring for up to eight patients at a time—all with multiple medications. We haven’t the time to wait in the queue—our morning drug round may start at 8 am and if we scanned as policy states, our drug round will not be over until lunch time and then it starts again! Time critical medication such as Parkinson’s and epilepsy drugs are often delayed because of this. Issue Workaround Risk Caring for many—unable to queue due to time. Scan one wrist band to get the drug cupboard open. Take ALL medications for ALL patient in numbered pots; e.g. bed number 1= pot labelled 1. Wrong patient, wrong drug, wrong dose. Drug cabinet far from ward area. Print multiple wrist bands and have them in your pocket. Wrong patient, wrong drug, wrong dose. Overreliance on technology While barcode scanning is designed to catch problems before they happen—for example, providing the medication to the wrong patient—it can also create a false sense of security. Some staff trust the system so much that they ‘forget’ to double-check what they’re administering. I’ve seen cases where the scanner didn’t flag an issue, but a second manual check revealed a potential mistake. No system is fool proof and human judgment is still essential. Issue Workaround Risk Blood administration—alert and checklist fatigue, over reliance on computer system information. No second checking. Wrong patient, wrong blood, wrong drug. Alert fatigue and workarounds Another challenge is the constant alerts. The system is designed to notify us about potential drug interactions, duplicate doses or allergies, but sometimes it feels like we’re bombarded with warnings. Often these warning are because of a previous incident and the pop-up is seen as the solution. When you’re dealing with dozens of pop-ups, it’s easy to develop ‘alert fatigue’ and start ignoring them, which is dangerous. Issue Workaround Risk Multiple alarms flagging and ‘hard stops’. Alerts overridden, checks on the scanner blindly ticked off the checklist. Wrong patient, wrong blood, wrong drug. Training and adoption challenges Not all staff are equally comfortable with technology and training can be inconsistent. New nurses, agency staff and those who aren’t used to the system may struggle, leading to mistakes or delays. And when changes are made to the system, not everyone gets the same level of training, leaving gaps in understanding. Training is often seen as the solution to this problem; it in in some cases, but there is far more to it than training. Integration issues Ideally, the scanning system should integrate seamlessly with electronic health records (EHRs) and pharmacy databases. Unfortunately, that’s not always the case. Sometimes, medications don’t appear in the system properly or there’s a delay in updates. This creates confusion and extra work as we double-check records manually. Patient-specific challenges We also face issues with patient wristbands. If a wristband is missing, damaged or poorly placed, scanning can be a nightmare. In critical situations—like when a patient is unconscious or in distress—trying to scan their wristband adds another layer of complexity we don’t always have time for. In healthcare, ensuring patient safety requires a deep understanding of how work is actually performed, known as 'work as done', rather than how it is ideally designed or imagined ('work as imagined'). The gap between these two perspectives can have serious consequences, making it essential for healthcare leaders to recognise real-world challenges and build systems that support safe and effective care. Issue Workaround Risk Administering a sedative for a combative patient. No scanning—override device. Wrong patient, wrong blood, wrong drug. What are the potential solutions? Understand the work system Healthcare is a complex, adaptive system where variability is inevitable. Policies, procedures and best practices often represent 'work as imagined', providing a framework for care delivery. However, frontline clinicians operate in dynamic environments where unexpected challenges arise. By studying 'work as done', organisations can identify discrepancies, improve workflows and implement practical solutions that enhance patient safety. Balancing accountability Achieving patient safety requires a careful balance between accountability and learning. A just culture differentiates between ‘human error’, at-risk behaviour and reckless actions. Instead of blaming individuals for system failures, organisations should focus on systemic improvements while holding individuals accountable for making safe choices. This approach promotes trust, engagement and continuous improvement. By involving frontline staff in the design, testing and implementation phases of introducing a new electronic system—or any new procedure, policy or tool—you may uncover these workarounds much sooner and be able to design them out. Addressing technological gaps When looking into new technologies to support healthcare, patient safety needs to be considered in the designed, development and implementation of new software and products. This means looking at how they are used in practice. It is not simply enough to put these in place, there also needs to be the infrastructure in place to support their operation. On some of the issues flagged earlier in this blog, improvements such as eliminating internet dead spots and having printers which manage their own updates would be small changes that could have a significant impact on how barcode scanning is used in hospitals. Concluding thoughts To bridge the gap between imagined and actual work, healthcare teams need psychological safety—the confidence to speak up about risks, inefficiencies and errors without fear of punishment. When staff feel safe to share their insights and concerns, organisations gain valuable real-world feedback, leading to proactive improvements. A culture of openness encourages learning from near misses and fosters a collaborative approach to safety. I had some reluctance to share this blog, particularly when working at the organisation where I encountered these issues. However, these workarounds and issues are not just within my practice, this is happening across the country in some shape or form. You just need to be inquisitive and look without judgement. Share your experiences What are your experiences of barcode scanning? What are the challenges you face? What workarounds do you have to use to do your job? Please comment below—you’ll need to be a hub member and signed in (sign up here). You can also email us at: [email protected]. Further reading on the hub Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox) Work as is done, work as imagined Electronic observations – how safe is it?

The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward.  When we set up the PSMN in June 2021, my aim was to create a private community space on the hub for patient safety managers and everyone working in patient safety to facilitate and nurture conversations between like-minded individuals. I wanted it to be a safe space for us to share our insights and lessons learned, to provide peer support for each other, and to collaborate on new ideas and solutions that would lead to improved patient safety. Up until then, a platform like this, that we could all access, was non-existent. Progress so far Since then, the initial aims for the PSMN have not only been met but the Network has grown and exceeded my expectations. We now have over 1100 members, from 652 organisations, in various roles and different levels of seniority, and each week we have around 90 join us for the drop-in sessions. We have members not only from England but Scotland, Wales and Ireland too and, although their systems and ways of working are often different, we gain a lot from each other. We have members from the NHS Trusts and ICBs, the independent sector, academia and policy makers, reflecting that patient safety is a partnership with the aim of safer care for all. To date, we have had over 100 drop-in sessions and more than 30 external speakers, including the Patient Safety Commissioner; national organisations such as NHS England, HSIB, NHS Resolution and Care Opinion; Patient Safety Partners and patient campaigners; patient safety leads from Trust early adopters of Patient Safety Incident Response Framework (PSIRF); and experts and researchers in Human Factors, investigations and PSIRF tools. We now have a list of interested speakers for months in advance. The drop-in sessions are a place for us to come together to introduce new thinking from both within and outside health and care that could accelerate patient safety improvements within our own organisations. It allows us to share knowledge resources that might be useful to others and enables PSMN members to gain a better, shared understanding of new policies, guidance, directives and regulations that impact our work. These meetings are a safe space where we can discuss and talk through issues that are hugely important to us all and necessary when there are organisational cultures that don’t always welcome sharing information openly and candidly. We don’t record the sessions or have an agenda as such, which helps with the relaxed and informal nature of the discussions. We sometimes write up a session for the benefit of those that can’t make it and, when we have permission to do so, add any information and presentations onto the PSNM community hub. "The PSMN network has been a breath of fresh air, where people from many different provider settings and across the UK have come together to discuss patient safety and quality improvement, it’s been great to hear the varied views and consider how different settings do things differently. Hearing the innovative work happening across and thinking of we can implement /share within our own areas is incredibly exciting.” “A great place to come together with like minded people to learn and grow together in a safe place that fosters psychological safety.” “I have really appreciated the agility of this group, very current topics every week, guest speakers, without over-formalising things. The content has been really thought-provoking and has a very "can-do" practical feel, things you could try out for yourself and put in place quite quick.” Support and collaboration We’re often asked, how do you measure the impact of the Network. I’m amazed at how it’s grown and evolved. From our weekly discussions and the resources, we share on a private community space on the hub, we’re becoming much more open with each other, sharing a lot more and developing ‘what we want to do’ and becoming a little bit more comfortable with our tools. It's now about how we pool our resources. For example, at one of our recent drop-in sessions we heard that some Trusts are appointing Human Factors experts to help them with better designing safety improvements and their incident response management. However, some Trusts can't afford this so there is some inequity here. Staff need to have access to these people, and they don't know how to do that. We started to think about how we might pool our resources and we’re going to arrange a discussion with the Chartered Institute of Ergonomics and Human Factors and other leads within the PSMN to see whether we can actually do that. It’s not just about sharing resources, it’s also about connecting people. Many of the richer interactions happen outside of the weekly drop-in sessions. People will share their contact details in the chat section during the meeting and they go off and talk to each other. For example, someone in the independent sector wanted to access other independent providers and GPs and through contacts in the Network they were able to access these. Smaller organisations, such as hospices, have found each through the Network, and can support and share patient safety issues and improvements with one another. “This network is my safe space, a weekly point in time to be inspired, share ideas and meet with like-minded people all trying to tackle the complex world of NHS patient safety. I have made so many networks from this group, and realised that we are not all alone in our challenges and opportunities to improve!” The new Patient Safety Partners have now joined our network and because many of them are lay people we’ve started to change the way we speak. We can sometimes be guilty of using acronyms or ‘NHS speak’ and we’re trying to get away from that and speak in plain English and ensure we are inclusive to everyone. One of the surprises of the PSMN is that academics want to join. At first, I thought that they didn't really have a place within the Network; I couldn’t see how they would link in. However, we invited some academics to talk about the theory of some of the tools and concepts around patient safety incident investigating and improvement. Listening to them speak, I realised that they can only write the theory if they see ‘work as done’ and we can only do the theory if we include them. I hadn’t realised we needed each other quite as much as we did. Since then, we’ve got many academics and universities involved and we have access to them whenever we need them. I've recently worked with an academic researcher at King's and they’ve come to the hospital and we’ve tested out their theory on Safety II. We’ve come together so they can see why I can't do it or what I'm having trouble with and we’ve been helping one another. Informing and influencing change We are now being seen as a group that can inform and influence agendas and policies. Recently, the PSMN had been used as a forum to collate patient safety managers and risk leads' concerns about the rollout and implementation of the LFPSE service, with a number of these issues being raised by Patient Safety Learning on behalf of the Network with NHS England. This has helped to contribute to a change of NHS England approach to LFPSE, causing it to pause a proposal around event types in the new system in response to the concerns raised. Providing user feedback is helping deliver a better and more coordinated service. How are we organised and funded? This is a completely free service for anyone who meets the criteria to join (working in patient safety in the UK). Patient Safety Learning run the community site on the hub and manage all the meeting logistics and Friday meetings invites. I coordinate the speakers invites and share the drop-in session chairing with patient safety colleagues and Helen Hughes, Chief Executive of Patient Safety Learning. We receive a small grant from BD that provides Patient Safety Learning with some tech set-up funding for the forum on the hub. I’m really appreciative of this support and we’d welcome a contribution from others that would help us fund the write up some of the discussions for wider dissemination and learning. Maybe something for the NHSE to help with or other industry partners? Where next? With the changing approach to incident reporting and investigation, PSIRF has given rise to new-found opportunities and freedom of investigation and incident management. Although this is an exciting time, there are few resources out there on how patient safety leaders are going to apply these new approaches for learning, action and improvement. We all have different ways of working, different ways of investigating incidents and different questions that might need to be asked when doing investigations. The PSMN allows us to discuss openly these changes and challenges with each other and share our experiences and learning. “1 hour of my week where I come away feeling that I have met with peers and extended my knowledge!” We have been invited to share our journey and present at conferences, such as the HSJ Congress and the Health Care Plus conference. Having heard one of our presentations, we were approached by a Publisher to write a book. This book, written by people working in patient safety management for patient safety management people, will explore the theory of safety and translate this into practice using case studies from members of the PSMN, identifying the gaps between the theory and practice. The book will be published early next year. The PSMN has inspired new networks. For example, the Patient Safety Partners now have their own network hosted on the Patient Safety Learning hub. A new network is about to be started – the Patient Safety Education and Training Network. This is a network to share resources, provide coaching and support for staff within these roles. We are also thinking about setting up an ICB network and a network for associate and directors of patient safety. We also have a LFPSE group who are collaborating and co-designing their own network. Already, we see a national Patient Safety Management Network with many subgroups that come together and feed into this one network. In fact it’s evolving so much that it needs more oversight and coordination. I would love to see Networks in different countries, for example in the US and across Europe, and we would then join up as a global network. We are not there yet, but one day. I am very excited to see where the PSMN takes us next. How to join Do you work in patient safety and are interested in joining the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email [email protected]. And if you would like to discuss setting up other networks, we’d love to hear from you and support you.

Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward. The phrase work as imagined vs work as done is often used within patient safety but it's not always an easy concept to explain. I recently tried a new tactic to bring the realities of this concept to life, and show why it is so important to address these issues - in this case relating to a mental health pathway in A&E. My aim was to explain how some of the policies we try to use don't actually work well together in practice when we have a patient come to A&E with a both a mental and physical health problem. I started off by printing every piece of policy, guidance, standard operating procedure, related documentation on the trust intranet, HSIB reports, NICE guidance and anything I could find from the wider NHS. I pinned it across the walls in the meeting room. There were more than 150 items relating to how we should care for the patient in these circumstances. We put the pathway that we 'imagined' at the top, like a process map along the wall. We then placed all of the policies and documents below the pathway at the relevant points. Then I got the staff to tell me what actually happens. It became clear very quickly that the policies contradict each other. In trying to follow two policies, you couldn't actually adhere to either one properly. It was impossible for staff. Once we did that exercise, participants in the room could see how the people writing policies did not perhaps understand how 'work is done'. So it was decided that any new policy that encompassed this mental health pathway for A&E would be co-written by patients, families and the staff doing the work. Importantly, this would include all staff involved - admin, clinical and management. Once that had been written it would go through stages of testing to make sure it was working well and to incorporate necessary flex in the system when unexplained or unintended things happen. We would look at and test the vulnerabilities within that system or process. The exercise took time and effort but it was an effective way to show people the challenges and barriers to safe care in a specific context. My advice to others trying to do the same would be to get it all out, expose it, make it as visible as possible. Sometimes you have to be the one to put the writing on the wall. Related reading Postcards from work: Exploring archetypes of human work through micro-narratives Work as is done, work as imagined Electronic observations – how safe is it? Proxies for work-as-done: a blog series by Steven Shorrock, Humanistic Systems Share your thoughts What did you think of Claire's example? Could you see this working in a different area of healthcare?Do you have any tips or techniques to share that could help others explain the challenges they face on the ground to large groups of people? Share your thoughts by commenting below (sign up here first for free), or get in touch with our content team at [email protected]

In this blog, Claire Cox, Quality Improvement and Patient Safety Manager at Guys and St Thomas' Hospital NHS Foundation Trust, explains why and how she developed the Patient Safety Management Network. She looks at why the network is needed, what it has achieved so far, its aims for the future and how patient safety managers can get involved. Belonging to a group, a tribe, is important to me. Shared challenges, shared purpose, shared experiences and shared knowledge in what I do - these are the reasons why it’s important to me. Alone, we are not able to reach our full potential, but together we are strong and are able to stand on the shoulders of giants. Why do we need a network? For the past few years, a perfect storm has been brewing. The need for a network of patient safety managers has never been more evident. There were three themes playing on my mind - each one was troubling me and affecting the way I was performing at work: 1. Recurring harm Every year, avoidable harm leads to the deaths of thousands of patients, each an unnecessary tragedy. Unsafe care also causes the long-term suffering of tens of thousands and costs the health service billions of pounds. Many people have been doing good work over the last 20 years, but patient safety remains a persistent problem.[1] This was evident during my Darzi Fellowship. Understanding why learning from incidents was not shared between trusts, departments and wards was fascinating. There are many barriers to why we don't share, some of which are deep-rooted in ‘the way things are done around here’ - the organisational culture and unwritten rules. But the overriding barrier was that there was no mechanism to share. If there was a mechanism to share, would it even make any difference? The only way to find out was to try, so in 2019 Patient Safety Learning launched the hub, a free platform to share learning for patient safety. A knowledge repository with open access for all. So far the hub has had 10,000 resources uploaded and has had 637,000 page views from over 200 countries, with communities of interest for people to discuss patient safety concerns and how to address them. the hub is a fantastic resource, but what we need is more of the human element - human interaction where tacit knowledge is shared. 2. Isolation I started my first patient safety management role in September 2020, as we were coming out of the first wave of the pandemic and heading straight into the second. Times were turbulent. I wasn’t based in the office and working from home made forging relationships tricky. The feeling of isolation was particularly challenging for me. The need to reach out was strong. When working clinically as a nurse, the bond with my colleagues was strong. As nurses, no matter where we work, we understand each other. We understand each other’s challenges, we are able to support each other and we know we are not alone. There are also many of us, so it’s not too difficult to find another nurse where you work to debrief, learn from each other and gain support. Coming from working clinically to now working as a patient safety manager, I miss the sense of belonging. I no longer fit into the ‘nurse’ box, at least that’s the way it feels to me. There are fewer peers around me that I can debrief, share and learn with. 3. Roll out of Patient Safety Incident Response Framework (PSIRF) Currently, we are stuck on a hamster wheel of investigating; investigating in such detail and at such volumes that we have no time for organisational learning, implementing robust actions or involving families and patients. The PSIRF is a key part of the NHS Patient Safety Strategy published in July 2019.[2] It supports the strategy’s aim to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This strategy gives permission for the healthcare system to ‘do safety differently’. I know I am very excited about the new framework. The whole reason I came into patient safety was to make it easy to do the right and safe thing, but there are still so many questions about PSIRF: How will it work? What do I need to do to start making changes? What methodologies do I use? What training do I need? Where do I start? To test the PSIRF, NHS England is first working with a small number of early adopters who are using an introductory version of the framework in their organisations. My Trust is not an early adopter, so we remain using the existing Serious Incident Framework.[3] Each trust has nominated Patient Safety Specialists (PSS) - in my Trust, they are the directors of patient safety. They will have the responsibility of leading the changes, whereas I will be implementing their strategy. There is a PSS network which has been created by NHS England to keep trusts abreast of how the early adopters are proceeding and provide updates on implementation timelines. However, I am unable to join this network as I am not a PSS. This network does not include my peers. I want to reach out to others on what I would call the ‘nuts and bolts’ of patient safety: how to reduce pressure damage, how to capture Duty of Candour, how to interview staff after a serious incident, how others involve patients and families.[4] The PSS network certainly isn’t the right forum for that. How did the network evolve? Scoping what was out there and identifying need After realising that the PSS network was not aimed at people like me, I looked at what was around for patient safety managers. Some of us are clinical, some of us are not, so a platform that we could all access was non-existent. There were forums on specific issues such as falls and tissue viability, but I couldn't find anything that encompasses patient safety and the management of patient safety. I knew I wanted to reach out to others, but were others ready to reach out too? By putting out a call on social media, it became acutely evident that I wasn’t alone. A poll that I put out on Twitter came back with a resounding, "Yes – we want a network!" Developing shared purpose Having a shared purpose for the network was the key to success, so we decided on these aims: To facilitate and nurture private conversations between a community of like-minded individuals. To share our insights and lessons learned so that all may benefit from our collective wisdom. To provide peer support when others in our community are in need of help. To collaborate on new ideas, solutions and research that might lead to improved patient safety. To introduce new thinking from both within and outside health and care that could accelerate patient safety improvements within our own organisations. To gain a better, shared understanding of new policies, guidance, directives and regulations that impact our work. To share knowledge resources that others might use in striving to improve patient safety within their own organisations. To enable PSMN members to influence relevant regional and national policies and add their voices en masse to campaigns that seek to improve patient safety for all (either directly or indirectly). Ensuring a safe space One of the barriers to sharing concerns and stories is that we are unsure who we can share with. Sharing non-patient identifiable information is OK. Sharing policies, process and action plans is acceptable. But the narratives behind these policies and action plans are far more insightful - however, to get this information you need to speak to people face to face. In a funny way the pandemic did us all a favour, as we are now all experts in using Microsoft Teams and managing online meetings (although I still forget to unmute myself – there's always one!) We know and trust Teams, so it's been a great way of getting people from across the UK together cheaply and easily. To ensure we have ‘real’ patient safety managers there is a process for joining the network. Firstly, applicants need to be a member of the hub. Once they have signed up they are screened by me and when we know they are a ‘real’ patient safety manager, they gain access to the meeting links and the private community page on the hub I’m really grateful to Patient Safety Learning for hosting the network on the hub and helping us capture discussions, such as this latest blog about the amazing work of the Patient Safety team in Sussex Community Foundation Trust. And to BD for providing Patient Safety Learning with some tech set-up funding for the forum on the hub. Deciding on a structure "Not another meeting!" No, it’s not just another meeting. In our private community we have: no agenda no action log an informal setting no hierarchy cameras on no recordings drop in, drop out a summary note on the dedicated hub page for those that can’t attend. Progress so far The network launched on 25 June 2021 and so far: we have had 17 meetings. we have 150 members (and growing fast). we have had 10 external speakers including NHS England, early adopters and the Healthcare Safety Investigation Branch. we have discussed what is important to us, including subjects like human factors and investigation, involving families, medication errors and duty of candour. Measuring success and impact The impact this group has had on patient safety has not been measured, and would be difficult to measure. Getting caught up in trying to measure and justify the network isn’t my priority; my priority is to keep the network going. If people continue to attend the meetings, continue to share their ideas and continue to find solutions from each other – then the network is serving an important purpose and will continue. The future and vision In the future I see a national patient safety management network with sub-groups – one for community, one for mental health, one for acute care, one for primary care, one for care homes and one for ambulance services. Each of these sub-groups would feed up to the national group for a yearly conference where we would share and discuss learning across all groups. Currently, I convene the meetings. However, I work full time as a patient safety manager and it would require a full-time person to run the network for it to reach its full potential. But for now – we have a fledgling network with passionate people who want to make a difference and get it right. We have made a start and we are trying! How to get involved Are you a patient safety manager interested in joining the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email [email protected] References [1] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019 [2] NHS England and NHS Improvement, The NHS Patient Safety Strategy, 2 July 2019 [3] NHS England and NHS Improvement, Serious Incident framework, Last Accessed 25 October 2021 [4] Care Quality Commission, Regulation 20: Duty of candour, Last Accessed 25 October 2021