Patient_Safety_Learning

Stephanie O'Donohue is the Founder of TIGER UK Group, a social enterprise set up to help improve patient experiences of gynaecology care through collaboration. In this blog she introduces a new survey, asking patients for their insights on vaginal access procedures.  TIGER UK was born out of a belief that progress in gynaecology care lies in collaborative working. Bringing patients, healthcare professionals, researchers and other experts together every month to talk about some core themes, has been key to this. A recurring topic has been gynaecology procedures and the need for patient experiences to be used to inform and guide care. We are excited to have launched an important new survey: Survey link - Vaginal access procedures: patient experience survey The survey is designed to capture patient experiences and insights of vaginal access procedures such as coil insertions, cervical screenings, biopsies - and many more that fit the below criteria. Who can take part? We would like to hear from anyone who has had a healthcare procedure/s in the last 10 years that required access into or through the vagina and: took place in the UK was not done under general anaesthetic or with a spinal block did not take place during or around labour or childbirth. This survey comes with a trigger warning, so please consider this too. You must be 18 years old or above to take part. Closing date: 15 September 2025. Why are we doing this? Designed with input from patients, healthcare professionals and researchers, the survey aims to: Deepen understanding of the factors that influence experiences of vaginal access procedures. Capture patient insights to help guide improvements. Identify areas for further research. Share the survey Please help us share the link to the survey across as many forums, networks and platforms as possible - personal and professional. If you would like to print off a poster (with QR code) to display locally, please email [email protected] Register for updates Keep up to date with the progress and findings of the survey, please complete this short form - https://forms.office.com/e/P3aLVhZxRR Join TIGER UK If you are passionate about improving patient experiences of gynaecology care, join the TIGER UK network on Facebook or LinkedIn. Our members include healthcare professionals, researchers, patients and many more. The only requirements are that you are UK based, passionate about making improvements in this area, and committed to working collaboratively with those who have different insights. Photo: Stephanie O'Donohue

In December 2022 Dylan Cope, a 9 year old boy, died of sepsis after being discharged from hospital. A coroner found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”. In this recording, Corine Cope shares some key aspects on the NHS investigation into her son Dylan's death from her parental perspective, with a view to encouraging change.

In this anonymous blog, a continence nurse highlights the difficulties in delivering toileting support to patients in overwhelmed emergency departments. They explain the challenges staff face, how these impact patient outcomes and experience, and why this needs to be urgently addressed.  After reading a number of recent articles about the challenges of delivering safe care in overwhelmed emergency departments and corridor settings, I wanted to highlight another increasingly difficult issue. As a continence nurse, I provide toileting support for patients and guidance for staff to help maintain good care and outcomes. With emergency departments increasingly overwhelmed and patients being cared for in corridors, it is critical that we look at the impact on continence care and risk of harm. What are the challenges? Not enough toilet facilities. Not enough staff to accompany patients who need assistance to the toilet. Lack of private, dignified spaces. A reliance on incontinence pads but no capacity to regularly change pads or manage this well. What can this mean for patients? An increase in moisture-associated skin damage, especially among those who are incontinent or rely on staff for support with toileting needs. Skin damage that often begins in the emergency department continues to worsen once patients are transferred to wards. Delays in accessing the toilet. No access washing facilities until they are admitted to a ward, sometimes many hours after coming to the emergency department. Patients are often being cleaned and changed behind a screen in a corridor which contributes to both physical harm and emotional distress. What can be done? Although there are measures that can be taken to help reduce harm in these increasingly overwhelmed environments, they always come with other considerations. Increasing toilet facilities can help support good continence care where these are lacking. Bed pads like Ultrasorb can help where there isn’t capacity to change personal pads regularly and in private. Although bed pads can hold a lot of fluid and keep the moisture away from the skin for longer, they are not ideal as they encourage incontinence. Looking at staffing allocation could help but the reality is that these teams are extremely stretched and, in the emergency department, blood tests and urgent investigations need to come first. Too often there is no time left for continence care. Using the appropriate products such as moisturising wipes and the right barrier cream can also help improve outcomes and speed things up for time-poor staff teams. This situation undermines patient dignity and wellbeing and places added strain on staff and hospital resources due to the preventable nature of much of the resulting skin damage. I have been part of several multidisciplinary solutions—such as revisiting staffing allocations and exploring alternative toileting support options—and have escalated these concerns through the appropriate channels. Despite these efforts, the challenge remains very real, and the daily struggle for staff to maintain basic standards of continence care continues. I hope this issue can be given the urgent attention it deserves. Share your insights Have you experienced some of the challenges around toileting support in emergency departments, either as a patient, relative or a member of staff? Could you share your insights and experience to help others understand the safety issues? Comment below (sign up first for free) or email our editorial team at [email protected]

NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing their insights, opinions and reflections around PSIRF to support one another at this time of transition.   In this ‘Top picks’, we’ve selected ten to share with you.*  In this ‘Top picks’, we’ve selected ten to share with you.* 1. Is the NHS ready for PSIRF? A blog by Chris Elston Chris, a patient safety education lead, discusses whether the NHS is ready for PSIRF, looking at the role leaders will play in implementing it and how we need to change the mindset and the culture within organisations. 2. Reflections on PSIRF, patient engagement and why we investigate: a recent discussion at the Patient Safety Management Network This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating PSIRF. 3. Going forward with PSIRF – overcoming the challenges by Judy Walker Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help. 4. 'The PSIRF Hollywood collaborative': a blog from Jane Carthey, Tracey Herlihey, Claire Cox, Maureen Bankole-Allibay and Helen Hughes ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of shared learning along the way. 5. Making a positive difference to patient safety – Preparing for PSIRF Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how they are supporting members to be ready. 6. The Patient Safety Incident Response Framework (Bevan Brittan) Mark Amphlett, clinical negligence specialist, looks at the aims of moving away from the Serious Incident Framework, and the challenges of implementation. 7. Mind the potholes! Implementing After Action Reviews: A blog by the National AAR Reporting Template Team Using the potholes metaphor, the National After Action Review (AAR) Reporting Template Team share their reflections on implementing AAR and its challenges. Although the focus of this blog is on AAR, its messages are pertinent to other learning response tools, including the SWARM huddle, multidisciplinary team review and the horizon scanning tool. 8. Patient Safety Spotlight interview with Lucy Winstanley and Rebecca Gibson, PSIRF leads at West Suffolk NHS Foundation Trust Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust. 9. Patient Safety Spotlight Interview with Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England Tracey talks to us about the importance of putting users at the centre of developing PSIRF, and what we can learn from magicians about patient safety. 10. Shared insights: The Patient Safety Incident Response Framework Summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey. The session covered key elements of PSIRF and, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust. 11. NHS England - PSIRF Early Adopter interview: Patient safety incident investigator perspective (15 August 2022) In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. *PSIRF is continuously developing and these are the opinions and reflections from those working with it at the time of publication. Related content Top picks: PSIRF tools, templates and examples PSIRF Risk Register and Risk Management Plan: Free tool to help you transition. Join our community If you would like to join our hub community or become a member of the Patient Safety management Network, you can register for free here. Read our '7 reasons to join the hub' to get a flavour of how our community might help you. Share your views If you have insights, tools or knowledge to share relating to PSIRF why not comment below or get in touch with us at [email protected]. At Patient Safety Learning we are also always keen to share good practice, challenges and training resources that could help support safe care more widely. If you sign up to become a member of the hub, you can upload resources to the site, receive our monthly newsletter and engage with other members.