Patient_Safety_Learning

Physician associates are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor, providing care to patients in primary, secondary and community care environments.

First introduced in 2003, PAs have become increasingly talked about in healthcare and in the media, with many discussions focused on the safety of the current approach. 

We want to hear from patients and carers. 

• Have you, or someone you care for, got an experience of being seen by a PA that you would like to share?
• Do you feel more information about the PA role would be useful for patients?
• Do you have any other comments, concerns or perspectives you would like to add?

Please comment below (you'll need to sign up first, for free) or contact the team at content@pslhub.org

The 7th meeting of the Patient Safety Partners (PSP) Network focused on a presentation from Hester Wain, Head of Patient Safety Policy at NHSE, and Chris McIlveen, National Patient Safety Partner. Their presentation focused on the Patient Safety Partner role, what they are doing at a national level and the Involving patients in patient safety (IPIPS) framework. This was followed by a discussion focused on the presentation.

The presentation slides and resources mentioned during the session are linked to within the notes (attached below). 

Other points raised, outside of the presentation, included:

• Never Event consultation 
• Patient Safety Partner Workshop - 10 April
• Access issues - emails, the private online network space etc. 

Patient Safety Partners Network meeting notes 5 Mar 2024.docx

An interview published today on the hub that may be of interest:

At the meeting on 5 March, Hester Wain, Head of Patient Safety Policy, and Chris MCIlveen, National Patient Safety Partner gave a presentation to the PSP Network. 

The below links and attached resources have been shared by them following the presentation. 

Patient engagement resources on the NHS England website

• WPSD 2023 - World Patient Safety Day 2023 – engaging patients for patient safety (Various blogs and videos)
• Simple steps to keep you safe during your hospital stay (Video)

Various PSP resources (you will need to be logged into the NHS Futures platform to access these)

• Enabling PSP inclusion and enhancing diversity
• National PSP remuneration and expenses step by step 
• National Patient Safety team PSP FAQs 
• National PSP Mentor Handbook 
• National PSP mentors training and resources guide

Attachments include:

• Presentation at PSPN meeting (slides)
• Patient Safety Partner Mentor’s Handbook
• Involvement Payment and Expenses – a guide for PSPs and patient safety team programme areas
• Patient safety partner frequently asked questions (FAQs)

230802 National PSP FAQs ver 2.3.pdf 20230721 PSP_PPV remuneration and expenses.pdf 20220117 Mentor Handbook.pdf Presentation at PSPN meeting 050324.pdf

On 15/02/2024 at 15:39, Lisa Riste said:

Im on salt tablets for really low blood pressure - without them I keel over. My nominated pharmacy hasn't been able to get hold of stock - bearing in mind I'm on 6 x tablets a day so 168/28 days. I'm feeling lucky if they have 60 at a time.... It takes a huge amount of 'patient effort' to navigate this. Eventually the request lapsed and they couldn't get anymore so GP had to issue paper script and after 7 pharmacies I found one with 96 in stock - so another owing slip.

Im not sure people realise the time implications this has throughout the whole medicines journey? My solution (and please don't try this at home) was to reduce it to 5 per day - plus lots BP checking, then went to 4 per day to try to ensure I had some supply left. I have a BP monitor and had my condition for around 10 years so I know what I'm doing - I couldn't go any lower or my dizzy spells kicked in. I then tried to reorder from GP again - second pharmacy were getting some but dk when.

With 7 tablets left.... scarily close to trying to negotiate with hospital pharmacy to get a cardiology prescription for me, I won the lottery and my nominated pharmacy tested to say they had some in for me. Ive gone back to 5 per day to be on the safe side but am OK now til start of April. 

Daren't even mention HRT patches shortage - only one type I can tolerate due to adhesive allergies. 

Thank you @Lisa Riste for sharing your experience and the related safety risks of patients not being able to access their full prescriptions. Patient insights like yours will help to build a picture of the range of issues faced, and the impact these can have on individuals physical health and mental health. 

The 6^th meeting of the Patient Safety Partners (PSP) Network focused on the following points of discussion:

• PSP survey data.
• Using the collective voice and efforts of the PSPs for change and influence.
• Potential workshop to explore ‘what good looks like’ for the PSP role.
• Leadership and vision for the PSP role.
• Access to the private online area for the network.

Patient Safety Partners Network meeting notes 6 Feb 2024.docx

At the last meeting, members asked PSPN member Stephen to share the poster he had created to encourage patients and families to contact him. His initial draft poster (alongside a 'Freedom To Speak Up' poster) is attached below for anyone interested in doing something similar. 

@Stephen Heard 

Poster.pptx

Hi @Kellie Wilden, thank you for sharing your experience. The issues you raise regarding availability of medication and the associated challenges of changing brand are really interesting, and very frustrating for patients who need their medication. Thank you also for highlighting that this was via a private route too as it helps us to understand the wider picture and all of it's complexities. 

Have you been given any reason for the medication not being available or indication of when it would be? 

Thank you @Darren for sharing your knowledge.

Thank you @Darren for sharing yours and your daughters experience and insights. And for highlighting the wide ranging impact on people when they do not get their medication. Your perspective is of enormous value to this conversation. 

In your role as a pharmacist, do you get told the reasons for supply issues? Are there some common themes? Do you have any changes you would make to help the system run more smoothly and reduce supply issues?

Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? 

• Was there an impact on your health (physical and mental)? 
• Were you told the reason for it not being available? 
• Was the issue resolved? If so, how long did it take?
• If you are still impacted by medication supply issues, have you been told when you will be able to access them again?

To help us understand how these issues impact the lives of patients and families, please share your experience and insights in the comments below. You'll need to register with the hub first, its free and easy to do. 

We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes?

Please comment below or email us at content@pslhub.org

Notes from the meeting on 9 January 2024.

The 5th meeting of the Patient Safety Partners (PSP) Network focused on engaging patients and families in patient safety. These discussions developed naturally to include conversations around:

•    The impact of PSIRF on engagement
•    Different engagement approaches across different healthcare organisation settings and areas
•    Cultural enablers and barriers to engagement
•    The PSP role and where it should sit within the engagement process
•    Duty of candour
•    Wider engagement with the public, Healthwatch, coroners etc.
•    Using the collective voice of the PSPs for change and influence
•    Supporting tools, resources and literature.

There was also an update on the next steps for the PSP survey and the plan to have new people chairing the meeting in the coming months.

Members have also been asked to contribute ideas for future meeting topics and/or presenters. You can share your ideas here.

Patient Safety Partners Network meeting notes 9 January 2024.docx

Hi @Sabrinapsychologist

Thank you for reaching out via the forum. Capturing lived experience will be an important part of understanding the issues and how improvements can be made. 

We will also add your information about the study to the main 'Learn' library so we can share your research request via our other channels.

In an opinion piece published on the hub today Luke* talks about Post-SSRI sexual dysfunction (PSSD).

Long-lasting sexual dysfunction after taking antidepressants: Lack of recognition harmful to patients

Luke argues that further action needs to be taken if we are to see long-lasting improvements in the care and treatment of patients with PSSD. He calls for:

• Widespread acknowledgement of the condition.
• Doctors provided with up-to-date information and training (informed by lived experience) on the dangers of antidepressants and how to support patients.
• Warnings on instructions for the medications updated and prescribing clinicians alerted to ensure patients are adequately informed.
• An awareness and media campaign launched targeting patients, prescribers and the public.
• Funding secured for research that helps us gain an understanding of the underlying pathophysiology, identification of a diagnostic biomarker and, eventually, a cure for PSSD.
• Doctors listening to patients so they can understand how PSSD is a life-changing condition and be able to refer to support services.

Have you had an experience relating to the article? What do you think should be done to improve patient safety? 

Please comment below (sign up first for free) or get in touch with us at content@pslhub.org to tell us more.

This case study focuses on a North Staffordshire Combined NHS Trust project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources.

Following pathway changes, value and efficiency impact was noted in the following areas:

• Because head CT scans are provided by a neighbouring acute trust, reducing the number of  patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT  scan referrals and a £7,800 direct cost saving.
•  The number of patients not attending appointments reduced from 572 in the baseline period  to 379 after implementing pathway changes. While not a cash releasing saving this improved  overall efficiency and productivity for the service and contributed to a reduction in overall unit  price per attendance.
• At the start of the project, the average unit price for patients attending the memory service  was £280.93. Through a combination of direct cost savings and efficiency and productivity  gains arising from the revised pathway, this figure had reduced to £205.12 in the review  period.

Do you have a cost-saving or efficiency case study to share? What were the patient safety implications? Do you have resources or knowledge to share that can help others make positive changes?

Comment below (sign in or register here for free first), or get in touch with us at content@pslhub.org to tell your story. 

"One of the best examples I saw involved a case in which a worker was about to move a vehicle and trailer. The keys were in the ignition, but before starting the vehicle, he decided to perform a walkaround and discovered a mechanic was working underneath the trailer. Together, they agreed to take the keys out of the ignition and established a tagging system to ensure nobody else would inadvertently move the equipment while it was being worked on."[1]

According to this article by Safety Management Group, just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns an organisation's safety philosophy into a clear reality.

Do you use a 'good catch' reporting system in your health and social care setting? Has it made a difference to safety culture or behaviour? How easy was it to implement? Do you recognise and/or celebrate staff for reporting incidents? 

Or perhaps this is something you'd like to implement. What would you like to ask others who have tried it? 

Share your experiences and questions in the comments below. You'll need to register for free first. 

Related reading:

• Near-Miss and Good-Catch Reporting
• Promote a culture of safety with good catch reports
• Using good catches to increase worker ownership of safety
• 5 Examples of good catches in healthcare and how to implement a near miss campaign

[1] SMB. Using good catches to increase worker ownership of safety. Accessed online 9/08/23. 

Hi @Lorraine 2 Many thanks for sharing your positive experience of undergoing a hysteroscopy procedure.

I am very pleased to hear that you felt supported, informed and that the pain was manageable. Sharing good practice examples is vital, as you say, for improving the quality of care more broadly in this area. Routine collection of pain scores is also important, as you have also highlighted, if we are to understand the prevalence of high levels of pain. 

If you have not already seen this, the calls to action at the end of this blog may be of interest to you:

Thank you again for sharing your experience

Thank you for sharing your experience.

I am so sorry you went through such pain. It is interesting to hear that the medication you were given to relax the cervix and uterus helped to some extent, I am unsure how often this is offered.

At Patient Safety Learning we continue to call for more research and training in this area, and for all pain management options to be consistently offered to, and discussed with, women undergoing IUD procedures.

Most importantly we are calling for women to be listened to and their experiences routinely captured by health services so the extent of these experiences can be fully understood. Thank you again for sharing yours.

The following account has been shared with Patient Safety Learning by Jen*:

"My first coil insertion and later removal were both done at different GP surgeries and were both agonising. I have broken bones and torn ligaments before, yet nothing compared to the pain I experienced in and after those procedures. For my second coil insertion, I felt I was prepared as I was going to a health centre where I would receive a local anaesthetic and numbing gel, and the procedure would be done by expert nurses. I also took paracetamol beforehand. Still, the pain was so agonising that I screamed. When it came to getting up, they told me I was white as a sheet and then I fainted. There were two nurses there and they had no idea what to do with me. I couldn't stand without my legs collapsing under me. They offered me ibuprofen and visibly panicked when I reminded them I am allergic to it; it was like they had run out of options. Eventually they told me they needed to close so sent me on my way. I had no one with me and drove myself home - I convinced myself I was being very silly and weak because if it was that bad, they'd have called for an ambulance or at least advised me to call a friend, instead of allowing - in fact encouraging me - to drive myself home. I screamed and sobbed in pain all the way home, where I managed get myself a hot water bottle and to drag myself upstairs to bed. I found leftover tramadol from when I broke my ankle, and it didn't touch the pain. I eventually passed out again. The pain lasted for days, and I didn't feel able to tell anyone what was wrong - I had been told by many doctors for many years that I had a low pain threshold and thought that my experience was a reflection of that. I felt a bit pathetic and weak, to be honest. 

"During all of my coil appointments, I was told I had a tilted uterus which they said was very common, and why the insertions had been so 'tricky'. I was later diagnosed with endometriosis and adenomyosis and was told they were common causes for a tilted uterus! There was no mention of those conditions as a possible cause when previously discussed, it was just explained as being one of those things - which would suggest to me that there is a gap in education for healthcare providers. 

"To this day, that second coil fitting is of the most traumatic experiences I have ever had."

*The patients name has been changed

Hi @Flávia

Thank you for responding. Your collaborative project sounds very interesting, we would love to hear more. Please do get in touch via content@pslhub.org. 

• Perhaps you have ideas around how safety can be improved in your field of work - whether that's in a hospice, hospital, charity or care setting. 
• Or you might have been part of a project that has improved safety and would like to share that with others.

Infiltration is when fluid or intravenous drugs are administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but  the  drugs involved are called vesicants which  can damage the tissue and cause serious harm to the patient.

The National Infusion and Vascular Access Society (NIVAS) are leading a campaign, to improve awareness of infiltration and extravasation and reduce avoidable harm. 

• Do you have insights to share on this topic?
• Perhaps you are a patient who has had an extravasation injury?
• Or a healthcare professional who has insights to share around making improvements?

Share your thoughts below (you'll need to register for free here first).

Hi @perbinder thank you for posting. @Claire Cox might be able to help share your request among relevant networks.

Hi @Sophie Osullivan

It might be worth contacting @Kirsty Wood who has done a lot of work in this area. She provides her contact details above.

Best wishes

Stephanie