Patient_Safety_Learning

Embedding the Patient Safety Partner role has been approached differently by different Trusts and organisations. In this presentation, Patient Safety Engagement Manager, Lea Tiernan talks about how they have worked hard to  develop the role at Imperial College Healthcare NHS Trust in a meaningful and strategic way. Lea is joined by Armine Afrikian, a Patient Safety Partner to explain more about: their five Patient Safety Partners how they have developed the role workstreams highlights challenges the Patient Safety Engagement Manager role. Join the Patient Safety Partners Network In June 2023, Patient Safety Learning established the Patient Safety Partners Network. The network meets monthly in a virtual capacity and now include more than 150 Patient Safety Partners. These meetings provide a supportive and safe space to: discuss the barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working with NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. If you would like to attend a Patient Safety Partners Network meeting as a guest speaker, please contact us at [email protected]. Related reading Patient Safety Partners: examples of impact: Speaking to members of the Patient Safety Partners Network, as well as a manager of five Patient Safety Partners, we hear how their work is having a positive influence on patient safety. The voice of the patient safety frontline: Chris Wardley, Patient Safety Partner at a large NHS hospital trust, introduces the Patient Safety Partners Network (PSPN). Patient Safety Partners – lack of role clarity a barrier for impact: this shares insights from areas of good practice, where the role has been well support and integrated locally. These examples show how clarity and guidance has helped to remove barriers, enabling PSPs to have a positive impact for patient safety, as intended. Patient Safety Partners: recruitment and induction: the knowledge captured in this blog provides guidance to anyone involved in embedding the Patient Safety Partner role within their organisation. It also includes advice for Patient Safety Partners to help them navigate their new role, settle in and have a positive influence on patient safety. Patient Safety Partners: influencing for safety: this includes some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have greater influence and impact. Developing the Patient Safety Partner role: Imperial College Healthcare NHS Trust share their approach: an interview with Lea Tiernan, Patient Safety Engagement Manager at Imperial College Healthcare NHS Trust, about how they have developed and embedded the Patient Safety Partner role. Lea explains what they have done practically to support those starting out in the role and to integrate them at a strategic level.

The Patient Safety Partner (PSP) role was introduced in 2022 by NHS England as part of its Framework for involving patients in patient safety and the National Patient Safety Strategy. In this blog, we explore some early examples of the impact the Patient Safety Partner role is having. Speaking to members of the Patient Safety Partners Network, as well as a manager of five Patient Safety Partners, we hear how their work is having a positive influence on patient safety. Highlights from Suffolk and North East Essex Integrated Care Board Michelle Grimes is a Patient Safety Partner at Suffolk and North East Essex Integrated Care Board. She's been involved in several safety projects where she's been able to have direct impact. Michelle has drawn out four key projects she has been involved in as part of her role as a Patient Safety Partner. Developing information leaflets for patients and staff I have helped produce two important information leaflets, where a gap was identified. The first was to help primary care staff understand the shift to 'The Learn from Patient Safety Events' (LFPSE) approach and encourage their transition to it. This went to all of primary care, including community pharmacies who historically tend to have low levels of reporting incidents. Some reports have begun to come in from pharmacies using the new system, which is brilliant. The second was a patient information leaflet relating to harm caused by sodium valproate, signposting people to sources of support. It was collated in response to a pharmacist asking at our medication safety collaborative where she could direct patients. Adapting the duty of candour letter I have been integral to collaborative work to adapt the duty of candour letter. We have changed it to reflect a systems approach following patient safety incidents that have happened whilst in the care of more than one organisation. Helping families raise concerns I have also been involved in the implementation of a service for families and carers. ‘Call 4 Concern’ helps people request further clinical opinion if they feel their relative is deteriorating and it isn't being recognised, or they feel their concerns are not being heard. Raising awareness of the role On World Patient Safety Day last year we presented an outline of the Patient Safety Partner role and how we hoped to develop it to an audience of various health professionals, service users and third sector staff. The feedback was that people felt it was positive to have patient/carers/relatives’ views represented in this new role, and they looked forward to seeing it develop. Improving ventilation standards at United Lincolnshire Hospitals NHS Trust Elaine Freeman is a Patient Safety Partner at United Lincolnshire Hospitals NHS Trust. Below, she describes how she helped improve standards of ventilation in treatment rooms across the 1000-bed Trust. Our Trust implemented the Patient Safety Partner role in September 2022, and we were all given a portfolio to manage. Due to my nursing background, I was given a clinical portfolio. This included attending the Infection Prevention and Control Group. It was through this group that I became very concerned about a ventilation report, particularly regarding treatment rooms. After various conversations, some research into ventilation guidance, and raising my concerns at committee meetings, I became part of a small working group led by two wonderful senior nurses. Our focus was to gather evidence that would drive change and improvement. Our first report identified rooms unfit for purpose, due to poor air exchange etc. Since then, a great deal of change has taken place for example: some rooms have been downgraded in relation to what procedures can take place the swapping of rooms to ensure good air exchanges improvement of air changes to some rooms by the estates engineers ensuring that the treatment rooms are not also used as a store room no cloth covered furniture or poorly fitted blinds that cannot be cleaned no mobile ventilation units hanging out of a window. Further insights from Patient Safety Partners In addition to Michelle and Elaine’s examples, Patient Safety Partners have been sharing further feedback on the early impact they are having in their roles: “One of the things that I have recently been involved in as a Patient Safety Partner is working with the Falls Group as an actor in a series of videos to highlight potential falls risks. The videos are currently being finalised, but it has allowed me to have an input into how falls might be reduced.” Colin Fiske, Patient Safety Partner at United Lincolnshire Hospitals NHS Trust. “An older lady was brought into the emergency department and unfortunately died. Due to the number of patients in the emergency department there were two patients to each resus bay. So when this lady came in and staff were attempting to save her life there was another patient in the bay who unfortunately witnessed all of this. There was a full Patient Safety Incident Investigation report on this and the report indicated that the staff involved had received support, but there was no mention of any support being provided to the other patient. As a result of me raising this, the patient has now been given all the relevant support.” Patient Safety Partner. Designing a strategy with Patient Safety Partners In a recent interview for the hub, Patient Safety Engagement Manager, Lea Tiernan explained how the five Patient Safety Partners in her team were integral to developing their initial strategy: “Early in their tenure, the Patient Safety Partners and I met fortnightly to design our initial strategy for involving patients in patient safety. We used the model for improvement to approach this, and after generating a driver diagram, we broke the work down into five workstreams. These include: Patient Safety Partner programme. Community engagement. Staff engagement and training. Learning response engagement. Equity and inclusion. The Patient Safety Partners expressed an interest in the workstreams, and we have at least two partnered with each.” Share your experience as a Patient Safety Partner It's great so see the impact Patient Safety Partners are already having. We'd love to collate more examples. If you are a Patient Safety Partner and would like to share how you are making a difference (big or small), to inform and inspire others, please contact our editorial team at [email protected]. Join the Patient Safety Partners Network In June 2023, Patient Safety Learning established the Patient Safety Partners Network. The network meets monthly in a virtual capacity and now include more than 150 Patient Safety Partners. These meetings provide a supportive and safe space to: discuss the barriers and opportunities share successes discuss how they can use their collective voice to make a difference for patient safety. Only Patient Safety Partners working with NHS organisations in England can join, although experts are often invited to present or discuss specific topics. If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here. If you would like to attend a Patient Safety Partners Network meeting as a guest speaker, please contact us at [email protected]. Related reading The voice of the patient safety frontline: Chris Wardley, Patient Safety Partner at a large NHS hospital trust, introduces the Patient Safety Partners Network (PSPN). Patient Safety Partners – lack of role clarity a barrier for impact: this shares insights from areas of good practice, where the role has been well support and integrated locally. These examples show how clarity and guidance has helped to remove barriers, enabling PSPs to have a positive impact for patient safety, as intended. Patient Safety Partners: recruitment and induction: the knowledge captured in this blog provides guidance to anyone involved in embedding the Patient Safety Partner role within their organisation. It also includes advice for Patient Safety Partners to help them navigate their new role, settle in and have a positive influence on patient safety. Patient Safety Partners: influencing for safety: this includes some suggested approaches and actions that Patient Safety Partners and trusts might take to help the role have greater influence and impact. Developing the Patient Safety Partner role: Imperial College Healthcare NHS Trust share their approach: an interview with Lea Tiernan, Patient Safety Engagement Manager at Imperial College Healthcare NHS Trust, about how they have developed and embedded the Patient Safety Partner role. Lea explains what they have done practically to support those starting out in the role and to integrate them at a strategic level.

EIDO Healthcare’s upcoming in-person conference on 26th November will focus on how improving informed consent practices can directly enhance patient safety. The event is organised by Julie Smith, EIDO’s Content Director and a topic lead for Patient Safety Learning's hub. ‘The Consent Conundrum: Legal Insights and Practical Solutions’ will explore how medicolegal expertise and practical approaches to informed consent can prevent medical negligence and improve patient outcomes. Discussions will include case studies highlighting patient experiences, the latest updates on consent, and the crucial link between informed consent and patient safety. Speakers include: Simon Hammond, Director of Claims at NHS Resolution Mr Parv Sains, Medicolegal Lead for RCS England and ASGBI Jonathan Webb, Head of Safety & Learning, Welsh Risk Pool Professor Vivienne Harpwood, Emerita Professor of Medical Law and Ethics, Cardiff University Helena Durham, Lay Patient Safety Partner and member of the Ethics of Clinical Practice Committee at Nottingham University Hospitals NHS Trust Attendees will receive a CPD Certificate and complimentary access to EIDO’s foundation e-learning course, “The Legal Aspects of Informed Consent” following the event. Spaces are limited and free, so don’t miss this opportunity to join vital discussions on improving patient safety through better informed consent practices. Register here.

The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been lost. Delays can impact treatment options and patient outcomes.  Dil Rathore is a Biomedical Scientist and Pathology Innovation Lead at Leeds Teaching Hospitals NHS Trust. In this interview, he tells us about a new tracking system he’s developed to reduce the number of patient tissue samples going missing.  Can you tell us more about the histopathology service you work with? Our histopathology service focuses on diagnosing diseases by examining tissue samples under a microscope. It is key in identifying conditions like cancer, infections and inflammation. Typically collected through biopsies or surgeries, samples are processed in various ways and we then assess the tissue’s cellular structure to detect abnormalities. Our findings guide clinical decisions, such as confirming cancer types, grading tumours and determining treatment options. The detailed reports produced by our service are essential in shaping patient care and are often discussed within multidisciplinary teams for comprehensive treatment planning. Are lost samples a problem? The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been misplaced or lost. Unfortunately, this ‘never event’ happens more often than is acceptable across the NHS and globally. While working in histopathology, I became interested in clinical systems, digital pathology and sample tracking systems. These systems are used by most NHS organisations, but they are prone to user error and are inherently flawed. They can only provide historical information about a sample's past, rather than its current location, which leads to uncertainty about where these precious patient samples are at any given time. Tissue blocks move constantly around the department to undergo additional processes. Dynamic movement around the department is both a necessity and also adds to the challenge of locating these samples. How does your new system work? From developing an understanding of sample tracking systems, I identified significant opportunities to enhance patient safety. Improvements were clearly necessary, but the technology to enable change still needed to be created. So, with support from the Innovation Pop-Up* I developed a new system. Our new system allows continuous, real-time tracking of the cassettes through Radio Frequency Identification (RFID) technology. Key elements It tells us the precise location of each sample and its movement through our histopathology department. Our custom tag provides the read ranges we require for the technology to work successfully in a clinical environment. Installing antennas and readers throughout the department allowed us to collect live data on the movements of our patients' samples. Our tag provides improved signal ranges, readability, and resilience of RFID technology in harsh processing conditions. How was this work resourced and developed? Thanks to seed funding provided by the Leeds Hospitals Charity, we were able to demonstrate ‘proof of concept’ with the innovation. Demonstrating the technological capabilities of the concept helped support an additional funding application to Innovate UK’s Knowledge Asset funding, which allowed us to scale the system as a minimal viable produce (MVP). Without support and funding, we wouldn’t have been able to develop the UK's first real-time histopathology sample tracking system. Were there challenges along the way? Innovating within the NHS has historically been difficult as the required infrastructure and support mechanisms have yet to be in place. Testing a new and/or unknown technology brings uncertainty and risk. Thanks to the support of Leeds Hospitals Charity, our Innovation Pop-Up team and the Pathology departments, we have begun to understand this process more robustly and agilely. This has led to the establishment of new methods for future innovation endeavours to allow more streamlined processes to test, and potentially adopt, innovations and new ideas. What’s next for this work? Although we are still testing and validating the data, we have seen some notable improvements since using the system: The RFID real-time tracking system offers never-before-seen visibility and data on our processes, ensuring samples are accounted for from collection to testing. This can reduce the risk of human error, leading to a more rapid turnaround of results and better patient outcomes. Pathologists' workflow can be streamlined as our labs can process samples and generate reports faster, thus optimising pathologist time, allowing for quicker decision-making and treatment initiation. The impact on patient care has been incredible. Diagnostic results are being delivered quickly, helping healthcare providers make prompt decisions regarding treatment plans, leading to improved patient outcomes and quicker recoveries. What advice would you give others wanting to develop innovations in the NHS? Carrying out due diligence and discovery is vital. Knowing what technology already exists and what current market offerings are available will begin to help shape innovation. Once you understand what you would like to see, explore current offerings to investigate if simple modifications could provide the solution. If this cannot be done, work in collaboration with other departments within your Trust (Scan4Safety, Clinical Engineering, etc.) to seek a solution. What’s next for this work? We will continue to collect data on the systems' performance and expand into other areas of the Trust to enhance the data. Once we have enough data, we hope to publish our findings. We are also exploring potential partnerships to help support the commercialisation of this innovation. If you are interested in RFID or RFID for Pathology Services, please contact Dil Singh Rathore ([email protected]), Pathology Technology & Innovation Lead, Leeds Teaching Hospitals NHS Trust. *a support programme at Leeds Teaching Hospitals NHS Trust for clinicians and entrepreneurs with ideas for new products and services that solve healthcare challenges. Share your insights and innovations Have you been been involved in rolling out a new way of working that has had a positive impact on patient safety? Could you share your approach and what you have learnt along the way? To find out how you can share your insights via the hub, get in touch with the editorial team at [email protected] or find out how to submit a blog here.

This webinar hosted by Hourglass is part of an exclusive launch of an eye-opening research project by Amanda Warburton-Wynn. This comes as a follow-up to Amanda's research from 2021, which lifted the lid on sexual violence against older people in hospitals across England, inspired by the tragic case of Valerie Kneale. Three years later, this updated research project reveals the current situation and how in just a few short years, the issue has changed considerably. In this webinar, Amanda will be speaking about how she conducted her research, what shocked her the most about her findings and what steps could be taken to prevent further abuse from occurring. Attendees can ask questions in a live Q&A with Amanda and members of the Hourglass team. Register here

In this 'Top picks', we've selected a number of key blogs from the hub relating to diagnostic safety. These have been shared with us by patients, healthcare professionals, researchers, third sector organisations and more. The insights captured help show the complexity of diagnostic safety and offer up ways to make improvements to prevent diagnostic delay or error.  Clink on the titles to access the blogs in full. 1. Using barcode scanning technology to improve blood group testing in unborn babies The NHS Blood and Transfusion (NHSBT) and the Scan4Safety Team in the NHS England National Patient Safety Team explore how barcode scanning technology has improved testing for the D blood group in unborn babies. 2. Pancreatic Cancer: striving for early, fast and accurate diagnosis Alfie Bailey-Bearfield from Pancreatic Cancer UK, explains the challenges associated with diagnosing pancreatic cancer, why fast and accurate diagnosis is so important, and why increased funding is vital to improving outcomes for patients. 3. Catching cancer early: what more can we do as GPs? In this blog, GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage. 4. Diagnostic errors and delays: why quality investigations are key Dan Cohen, international consultant in patient safety and clinical risk management, looks at the challenges around diagnostic error and delay, compounded by human factors, cognitive bias and the Covid-19 pandemic. Ending with a case study, he illustrates how high-quality investigations, that delve deeply into human factors and focus less on blame, are key to reducing harm. 5. Diagnostic safety: accessibility and adaptations– a (un)reasonable adjustment? Pavi Brar from National Voices, explains why accessibility needs and adaptations must be taken into account and addressed to enable everyone to access diagnostic services. 6. How early diagnosis saves lives: case study on aortic dissection The Aortic Dissection Charitable Trust explains why timely and accurate diagnosis of aortic dissection is critical for saving lives. By sharing Martin’s recovery story, they illustrate the positive impact of prompt testing and treatment. 7. Rheumatoid arthritis: would my life be different if I had been diagnosed sooner? A patient explains how her experiences of pain were dismissed after the birth of her first baby. Although her own research indicated she had rheumatoid arthritis, she had to battle misinformed and unhelpful doctors to get a referral to a specialist. 8. “Listening to a patient’s history for longer can help doctors make the right diagnosis” Maria Dahm and Carmel Crock tell us more about their research to explore the relationship between communication and diagnostic accuracy. The findings highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well. 9. Digital diagnosis—what the doctor ordered? Clive Flashman, Patient Safety Learning's Chief Digital Officer, looks at some of these new digital tools that are becoming increasingly available not only to clinicians but also for patients, and highlights some of the risks that they bring and considerations that need to be thought through. 10. Improving diagnostic safety in surgery: A blog by Anna Paisley Anna Paisley, a Consultant Upper GI Surgeon, talks about the challenges to safe surgical diagnosis and shares some of the strategies available to mitigate these challenges and aid safer, more timely diagnosis. 11. Applying a robust approach to digital clinical safety in diagnosis Ben Jeeves, Associate Chief Clinical Information Officer and Clinical Safety Officer, looks at the digital clinical safety aspects in relation to diagnostic safety. Share your experiences on the hub We would welcome your views on improving diagnosis for patient safety. Are you a patient who has been affected by a delayed, incorrect or missed diagnosis? Or perhaps a healthcare professional with an example of an improvement project that aims to reduce diagnostic error and improve outcomes? You can share your experience in our community forum (sign up here for free first), submit a blog, or email us at [email protected]. You can also find a number of existing resources, tools and stories relating to diagnosis and patient safety on the hub here.