PatientSafetyLearning Team

the hub is free and easy to join. Most importantly, it is helping to drive safer care in a number of ways: Still wondering whether to become a member? Here are our top seven reasons for signing up to the hub: 1. Access thousands of patient safety resources Home to a wealth of patient safety resources, you can browse or search our library (called ‘Learn’) to access videos, blogs, guidance, research, practical tools and much more. All our content is tagged so you can easily find other similar items of interest in our Learn library. Just click on the tags on the left-hand side of the page. Something missing? As a member you can help to build our content by uploading links to relevant resources or by sharing your own original content (more on that later…). Browse the ‘Learn’ library Search ‘Learn’ 2. Become part of an inclusive global community Our members come from countries across the globe, bringing with them rich insights from varied perspectives. the hub is a unique space where health and care staff, patient safety leaders, patients, researchers, policy makers and charities are untied by a passion for patient safety. As a member you’ll become part of this exciting and growing network, centred on improving care together. Sign up to the hub 3. Share your insights, experiences and tools We want the hub to be shaped by our members. That’s why we created the ‘share’ function, enabling people to contribute in a number of different ways… Perhaps you’d like to write a blog about a specific patient safety issue? Or shine a light on a project or approach that has had a positive impact on patient safety? Maybe you want to share your concerns around unsafe care and suggest system changes that are needed to prevent future harm? Take a look at the bottom of this page for some examples of how our members have contributed original content to hub. We think you’ll be inspired! As a member, you can also apply to become a Topic Leader. This allows individuals to contribute their expertise on a regular basis around specific topics. Share something Read about our Topic Leaders 4. Collaborate on key topics Our ‘Communities’ forum enables members to start conversations on topics of interest. It’s a great space for collaborating, asking questions, sharing resources and bouncing ideas off other members. You can also tag other members and ‘follow’ conversations allowing you to receive notifications when there is a new comment. Start a new topic of conversation (click on the relevant category to start posting, you’ll need to be signed up and signed in) 5. Build your network When you join the hub, you have the option to complete an ‘about me’ section which will appear on your hub profile for others to see. By using the member search function you can search for keywords that others have used in describing themselves in their ‘about me’ section. If you want to connect, you can message them via the hub. It’s a great way of finding people to network with on topics of interest. When you sign up to the hub you can also express your interest in joining specific, smaller networks, set up and run by our members. Simply tick the relevant box when registering. Do a member search (select the right hand tab, and make sure you are signed up and signed in to message people) Complete your ‘about me’ section on registration 6. Get the latest news and events Our ‘News’ section on the homepage brings you the latest patient safety media coverage. To find out about patient safety events that are coming up, take a look at our ‘Attend’ section. Another handy tip is that you can refine our ‘advanced search’ fields to look for key topics in either of these sections. For example, if you’d like to find out about any upcoming human factors events, simply tick the ‘Attend’ box when searching and enter your keyword/s. News Attend Advanced search 7. Keep up to date with a monthly roundup When you sign up to the hub, you can select the option to receive a monthly e-newsletter. This gives members a handy round-up of hub content, including recent blogs, resources, news and ‘hidden gems’ that may be of interest. A great way to get a succinct overview and keep your finger on the pulse. Sign up to the newsletter on registration What are our members saying? With more than half a million views since we launched less than two years ago, our members are finding the hub to be invaluable: “Having an external source which has such a focus and energy on patient safety is not only a place to go for information but also for support.” Jenny Davidson, Director of Governance. “Thank you so much for asking me to write this piece. Your amazing work at Patient Safety Learning is invaluable in helping to change the culture of the NHS to an open one of learn not blame, making it safer for all”. Lindsay Fraser-Moodie, GP trainee "We are so grateful for your help, support and using your platform to echo our concerns and call for help." Sophie Evans, Long Covid Support. “I’m finding it an invaluable resource. You have linked me with people I would not have met otherwise. It's a great share and learn together.” Steve Turner, Nurse Prescriber. Time to get started! So, if you’ve got an interest in patient safety and helping to reduce avoidable harm, sign up to the hub today and join our growing community. And most importantly, do not forget to sign in! Without signing in, you won’t have access to all of the great benefits of being a member. For more practical tips on using the hub and maximising your membership, you can watch this short film. We look forward to seeing you on the hub! Examples of original content from our members: Practical tools and resources Reducing intubation errors: A simple, accessible checklist to improve safety and support staff Midwifery Continuity of Carer: What does good look like? Improving safety for diabetic inpatients: 4 key steps Opinion pieces, blogs and interviews Raising concerns about PPE and ventilation as a Junior Doctor, a blog by Lindsay Fraser-Moodie “I’m going to Datix you” A child left waiting for ‘urgent’ surgery, a blog by Clare Rayner Five X More campaign: Improving maternal mortality rates and health outcomes for black women Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Medication delays: A huge risk for inpatients with Parkinson’s Through the hysteroscope: Reflections of a gynaecologist Obstetricians approach to proactive safety management Community conversations Painful hysteroscopy Safety Culture Survey References [1] World Health Organization, Global Patient Safety Action Plan 2021-2030, 3 August 2021. [2] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019.

1 Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths. 2 Midwifery Continuity of Care: What does good look like? In this video presentation, Trixie McAree, National Midwifery Lead for Continuity of Carer, gives a comprehensive overview of the continuity of carer model and how it impacts on patient safety. Trixie also provides advice and practical tips for teams setting up the continuity of carer model and explains why this transformation is key to improving outcomes. 3 Decolonising midwifery education Part 1: How colour aware are you when assessing women with darker skin tones in midwifery practice? In midwifery practice, skin assessment is an important element of any physical examination of women. This article published in The Practising Midwife, highlights ways in which midwives can develop confidence in skin assessment when caring for women with dark skin tones. 4 Breaking the taboo: the impact of severe maternal birth injuries on the mother-baby bond This report, produced by the MASIC Foundation, explores the impact of severe maternal perineal trauma on the physical and mental health of the women who sustained the injuries and on their relationship with their child. The report calls for several actions to improve care, including the national rollout of the RCOG OASI Care Bundle. 5 Taking action on the Ockenden report (University Hospital Southampton) This infographic has been produced by Katherine Barrio, Better Births Project Midwife from the University of Southampton NHS Foundation Trust. It sets out their plans against each of the seven immediate and essential actions outlined by the Ockenden Report. 6 Information on group B Strep translated from English into 14 other languages This information leaflet, produced by the charity Group B Strep in partnership with the Royal College of Obstetricians and Gynaecologists (RCOG), is aimed particularly at pregnant people and new parents with information about group B Strep. It has been translated from English into 14 other languages. 7 Postnatal Risk Assessment Matrix (PRAM) This resource was developed by Dr Cindy Shawley, Quality Improvement Lead for Maternity at Hampshire Hospitals NHS Foundation Trust. Included in the pack are a ‘holding your baby safely’ poster and guidance for the keeping mums and babies together in the first hour of care to support normal adaption to life. #Share4safety Are you a healthcare professional looking to share your frontline insights to help improve patient safety? Have you developed a resource or tool locally that others could benefit from? Or perhaps you have an experience to share around maternity safety, as a pregnant woman or birthing person? Join the conversation in our community forum on the hub, or get in touch with us by emailing content@pslhub.org. Join our global patient safety community the hub is an award winning platform, bringing together people from around the world who are passionate about patient safety and reducing unsafe care. It's free and easy to join so why not sign up today and join a growing community helping to drive safer care.

Related content: PPE guidance continues to put staff and patients at risk, by Dr David Tomlinson Raising concerns about PPE and ventilation as a Junior Doctor, a blog by Lindsay Fraser-Moodie How will NHS staff with Long Covid be supported? New FFP3 respirators may cut infection risk Hospital-acquired infection caused one-in-five covid deaths at several trusts

I’ve been a hospital doctor for 10 years, but in February 2020 I switched to GP training. As part of that I’ve spent the last 18 months in hospital rotating around different specialities. In December 2020 I rotated onto a Department of Medicine for the Elderly (DME) ward, populated with very vulnerable patients. The ward has five single side rooms, and six bays. There are mainly DME patients in the bays, but the side rooms are used by patients who need isolating for a variety of reasons. Originally built in 2005 as an ‘isolation ward’, it still retains that name. Throughout December and January during the UK’s second wave, the ward had a combination of Covid positive and negative bays and side rooms (as it had in the first wave). Concerns about the ward air As soon as I started work on the ward it was clear to me that patients and staff were getting infected from the ward air. We had devastating numbers of hospital acquired infections in both patients and staff. I knew that my colleagues were doing everything asked of them with regards to droplet precautions and hand hygiene as I could see what was going on in front of me. I started to read the science around airborne transmission of Covid, and it fitted exactly with what I was witnessing. UK PPE guidance wasn’t protecting staff As per UK infection control prevention (IPC) guidelines, we didn’t have access to higher grade respirator masks (FFP3s) unless we were doing what is called an ‘AGP’ (aerosol generating procedure). This was rare, so most of the time we were all in surgical masks whilst providing close Covid patient care. I know I certainly felt very vulnerable in a surgical mask and petrified of taking Covid home to a loved one, so I’m sure most my colleagues felt the same. Surgical masks are only designed to block large bits of virus droplets. However, Covid spreads primarily in smaller airborne particles called aerosols, which are expelled from an infected person’s nose and mouth (together with droplets) every time a person with Covid breathes, speaks or coughs. Unlike droplets, which drop to the floor within a few metres like the name suggests, aerosols are light and hang around in the air like invisible smoke in indoor spaces. Hence being outside is safer, as aerosols disperse quickly. It was previously thought that AGPs were the only way aerosols were produced, but this science is very outdated now, and we know that humans simply breathing is aerosol generating! The laws of physics dictates that you can’t get droplets without aerosols too. Aerosols cause Covid infection through inhalation. Loose fitting surgical masks will block a lot of aerosols, but some will also leak out, and in, around the poorly fitting edges. The closer you are to someone infected, the higher your chances of breathing in their exhaled aerosols. If that person is in a mask then your chances of getting infected by them is dramatically reduced, however very few patients when unwell in hospital with Covid can tolerate wearing masks. Staff caring for Covid patients have to get up close to unmasked Covid patients, putting them at high risk of inhaling short-range aerosols, which is why they should be in well fitted respirator (FFP3) masks which are designed to completely block aerosols. A recent observational study from Addenbrooke’s Hospital showed that staff on Covid medical wards in surgical masks had up to a 47 x higher chance of being infected with Covid than their colleagues who were also wearing surgical masks on non-covid wards (who had the same rate as community infections). Following the change in protective equipment to FFP3s for all staff on the Covid wards, the incidence of infection on the two types of ward was similar. Their risk of being infected at work was effectively eliminated. The risk to patients Being in an indoor environment puts anyone sharing the same air as someone infected with Covid at risk of inhaling their long-range aerosols. I noticed very early on that even patients in our side rooms were tragically contracting Covid on the ward, despite staff following all the guidelines on preventing fomite (surface) and droplet transmission. This especially got me thinking about the flow and quality of the air on the ward. Were the long-range aerosols drifting into the non-Covid bays and side rooms? Also, were unknowingly infected staff taking Covid in and breathing Covid aerosols out of the sides of their poorly fitting masks? I felt like it was probably a combination of the above, mainly the first as genomic sequencing studies show that patients are mostly infected by other patients. We were only being PCR tested once weekly, plenty of time to sadly infect a colleague or a patient before you knew you were infected. There is little chance to distance from colleagues or patients on the ward. When staff are spending 12 hour shifts in wards with covid patients and working together in close proximity with colleagues in a high-risk environment, they need the best masks available. We felt very helpless to protect our patients on the ward. Despite the best efforts of everyone on the fantastic team I was proud of be working with, we were having heart-breaking regular hospital outbreaks together with an alarming number of staff infections. The worst phone calls I’ve had to make in my career were the calls to the relatives, letting them know that their loved one had tested positive for Covid, often likely nosocomial (originating from the hospital). I felt like I was letting my patients and their family’s down, and it went against ‘first, do no harm’. I also wanted to speak up to defend my colleagues. It was clear to me that Covid wasn’t spreading on the ward as staff don’t wash their hands, or were wearing masks under chins, as some asserted without evidence. We were working through the most traumatic and challenging time of our careers, and I was not going to accept my hardworking, selfless colleagues being laden with unfair guilt. Individual behaviour may have played a small role at times, but it was not the cause of the huge issue of nosocomial Covid infections that we saw nationally in the UK this pandemic. Auditing the air and ventilation Wanting to help the situation, I spent hours reading on the topic of airborne transmission and reached out to experts in the field to learn more. I bought my own C02 and particle counter to audit the air quality on the ward, which showed it was indeed poor. I went around the ward looking for any ventilation extracts/inflows. I also spoke to our hospital estates about the ventilation and filtration on the ward (ventilation provides fresh air – it can be natural or mechanical, and filtration means air filters to clean the air. Air can also be cleaned using UV technology. It transpired that there was no mechanical ventilation or filtration on the ward, we were relying solely on natural ventilation (i.e. opening windows), which was very difficult to do in winter months and with safety latches on the windows limiting opening. Nobody knew the direction of air flow on the ward, particularly into or out of the side rooms. Raising concerns with my CEO I emailed our hospital’s CEO about my concerns regarding inadequate PPE and lack of attention to airborne spread within the hospital. He was fantastic and got back to me very promptly to kindly acknowledge my concerns. We had a meeting several weeks later, together with my ward manager, matron, and ward consultants. The head of infection control was invited, and I had emailed my concerns to the infection control team separately. I made it clear that I was by no means an expert on this topic (the experts are the engineers, aerosols scientists, and architects with a specialist interest in this area – we need to listen to them on this and work together to tackle it), but I simply wanted to raise the issue that the air we breathe in healthcare settings is incredibly important to reduce airborne disease transmission. Changes were implemented to improve safety In the second half of January 2021, my trust changed their own local PPE guidance to allow FFP3s for all staff caring for covid patients, if their manager felt the local risk assessment warranted this. National guidance still said surgical masks alone were adequate, but many trusts had begun to cotton on to the vast numbers of staff sickness on covid wards which were following national DHSC/PHE guidance. I am very pleased to say that since this time any staff member who has needed an FFP3 mask has had access to one. After the meeting to discuss ventilation and air cleaning, our CEO organised a trust ventilation audit to ensure the hospital meets the ventilation standards set out by NHS England. Obviously, it takes time to update inbuilt ventilation systems, so in the meantime any areas with poor ventilation have portable air cleaning (HEPA filters). This includes this ward that I worked on, which once again has Covid admissions. There are also window stickers on the ward that the ward manager and I stuck up, to remind staff of the importance of fresh air, and all staff always have access to FFP3 masks regardless of AGPs. My CEO thanked me for bringing this important issue to his attention and commented how difficult it was for them with the lack of national guidance for hospital trusts (and social care settings) on how to mitigate against airborne spread of Covid. You can see his comments at the bottom of this blog. UK guidance remains unsafe There has been plenty of guidance for trusts on how to clean surfaces, but no guidance on the most important mitigation measure of all – how to clean the shared air. DHSC/PHE PPE guidelines saying surgical masks were adequate for Covid patient care in the absence of AGPs also put trusts in difficult positions. National PPE guidance is still woefully inadequate. Their latest update in June 2021 leaves trusts to decide where FFP3 masks are required for staff, after saying for well over 12 months that they were only required in the presence of AGPs. In my opinion, they needed to come out and clearly say this was an error, and that all health and social care workers caring for Covid patients need access to FFP3 masks. Ideally re-usable ones, better for the environment, and often more comfortable for the wearer. If you have concerns locally… If you have safety concerns, speak to your colleagues. People were incredibly supportive of me speaking out. It was a team effort to make our ward a safer place for patients and staff. I am also very grateful to our trust’s CEO, for being an inspirational leader and taking the time to listen to, and act upon, my ‘Concerns from a junior doctor’ emails. I will always be indebted to him. Even if you do not have support, I would encourage anyone to speak out for what you believe is right, especially if the health of your patients is at risk. Being silent is being complicit. Ask, would you want a relative of yours being admitted to that ward and treated in that way? If the answer is no, you know what to do. Lindsay Fraser-Moodie Comment from David Carter, Chief Executive, Bedfordshire Hospitals NHS Foundation Trust: “When Dr Fraser-Moodie first contacted me, it was 12th January 2021. This period was probably the most difficult and challenging time for us during the whole COVID period, as like other hospitals, we were trying to manage the rising numbers of admissions and the risk of nosocomial infection which was becoming part of the national picture. Indeed that week has proven to be the week with the highest number of positive inpatients at the Trust during the whole pandemic. We relied heavily on the national guidance to drive our local policies recognising that whatever reservations we may have, compliance with that guidance was the safest position for us to take and indeed in relation to PPE in the early waves, the difficulty in the supply chain meant that hospitals had little choice. Dr Fraser-Moodie’s email to me challenged that guidance specifically in relation to the transmission risks and did so in a well - researched and informed way but also in a very personal way, bringing home the impact the pandemic was having on both staff and patients. It also chimed with the concerns we, and other members of staff, were starting to have regarding the way that the new Kent strain of the virus appeared to be spreading. Throughout the pandemic we have been fortunate to have been able to call on the wise counsel of our DIPC and microbiologist, Dr Mulla who himself was concerned about the difficulty in providing adequate ventilation, particularly on wards in winter when opening windows was very difficult. Myself and Dr Mulla took some time to talk to the ward about their concerns and also to explain some of the constraints we operate under, including our need to adhere to national guidance wherever we can. Nonetheless as a result of Dr Fraser-Moodie’s highlighting of these issues, we made some changes to our approach including a modification to our PPE policy which allowed for more local risk assessment, an increase in our purchase of portable air filtration units and the acceleration of our site-wide ventilation audit which is now guiding the infrastructure works on the site. I strongly believe that when individuals raise concerns, we have a duty to listen and only by creating a culture when individuals feel safe to do so can we learn and change and ultimately provide the care we aspire to. However those who raise concerns also have a duty to do so in the right way. In the midst of a pandemic it was incredibly important to not cause alarm amongst patients, not to damage the morale and reputation of the services being delivered and to recognise some of the practical difficulties inherent in managing the situation in an ageing NHS estate. Dr Fraser-Moodie found that balance and I would like to thank her for having the bravery to raise a concern but also doing so in a respectful, evidence driven way which made it much easier for me to engage in a non-defensive way. I am sure that Dr Fraser-Moodie will continue to be a positive force for change as she continues her career.” David Carter Related content PPE guidance continues to put staff and patients at risk, by Dr David Tomlinson New FFP3 respirators may cut infection risk Hospital-acquired infection caused one-in-five covid deaths at several trusts The scandal of insufficient PPE: Why healthcare workers were betrayed – and continue to be How will NHS staff with Long Covid be supported?