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A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds).   The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated.   The resources can be downloaded by NHS Trust Learning and Development teams to support a Trust-wide approach to essential learning and training.   Through short film and audio scenarios and case studies, Life Beyond the Cubicle shows why it is so important to involve family and friends, helps clinicians reflect on why they don’t do so routinely, and how they can overcome these barriers. The resources are engaging and interactive. The modules are: Introduction (includes guidance on how to use this resource) Module 1: Why do families and friends matter? Module 2: Assumptions and expertise Module 3: Feelings and fears Module 4: Confidentiality and Information Sharing Module 5: Safety planning Resources for family and friends They are free to the health and social care workforce. Further reading on the hub: Safer outcomes for people with psychosis Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count The future has been around for too long—when will the NHS learn from their mistakes?

This infographic by the College of Emergency Nursing Australasia gives practical advice on how to speak up if patient safety is compromised.

The Health Service Executive (HSE) Dublin North East’s Patient Safety Tool Box Talks have been developed to assist with the delivery of key patient safety messages within the workplace. Patient Safety Tool Box Talks© are not a substitute for formal training but rather recognises the need to embed patient safety into the workplace and as such are a support to formal more detailed training programmes. This approach allows the delivery of consistent short customised patient safety messages to staff in a brief intervention as part of a team meeting or at a shift change. The talks are designed to take no more that 5-10 minutes to deliver are capable of being delivered by a non-specialist. If questions however arise beyond the scope of the talk these should be referred to a specialist for clarification. This Tool Box also contains Guidance on Delivering a Patient Safety Tool Box Talk© and a number of talks on a variety of safety topics. Patient Safety Tool Box Talks© Theme 1 talks - Person centred care and supportre and Support Patient Safety Tool Box Talks© Theme 2 talks - Effective care and support Patient Safety Tool Box Talks© Theme 3 talks - Safe care and support Patient Safety Tool Box Talks© Theme 5 talks - Leadership, governance and management Patient Safety Tool Box Talks© Theme 8 talks - Use of information

This anonymous blog high lights the vulnerability of patients, especially when it come to consent. This is a shocking account of events by a well informed patient when they were wrongly consented for a gynaecological procedure.

This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time. We have all heard of the terrible stories of nurses going to the coroner’s court. These stories have been fed to us by our seniors, our mentors, our lecturers since we were students. "If you don’t document properly, you will end up in the coroner’s court, you might even get struck off!" These stories strike the fear of god into you. No one wants to go to coroner’s court, no one wants to be criticised for the work they have spent years training to do. No one wants to be publicly humiliated. This is my story of what happened when I attended a coroner's hearing on a patient who was in my care. I was a band 6 at the time. It was a usual day on the medical ward. Busy. I had a bay of six patients. Three of them were fit for discharge, but no community placement for them to go to, two medical patients and one who was a surgical patient. The surgical patient was under the medics and the surgeons. He came with abdominal pain; he was waiting for a surgical review. Many patients are under numerous teams on the medical ward. One of my roles is to ensure that they get seen by each team every day to ensure a plan for treatment. Today was no different. The patient was seen by the medical team who said "await surgeons". I chase up the surgeons, but they are in theatre. From experience I know that they will be out of theatre by late afternoon – so hopefully I can catch them then. In the meantime, the surgical patient becomes unwell. His blood pressure drops, his NEWS of 5 from 0. He is tachycardic. I call the medics who attend – they want me to call the surgeons… no answer. Intensive care team arrive – to this day I’m not sure how they knew to come, perhaps one of the medics called them? The intensive care doctors I hear raging down the phone at a poor surgeon who is in theatre. The surgeon comes to the ward and soon realises the gravity of the situation. There are discussion that are being had away from the bedside – I’m not sure what was being said or plans that were being made. I was not part of the process. I’m busy doing observations every 5 minutes as requested, plus trying to look after my other five patients. All of a sudden we are going to theatre. I’m still unsure what’s going on. What’s he going there for? The patient looks really scared. I bet I look scared too! I help wheel him down to the operating theatre. As soon as we arrive in the anaesthetic room he has a cardiac arrest. We try and resuscitate him to no avail. I went back to the ward; bewildered, sweating from doing chest compressions, confused and with tears in my eyes. I have a quick cup of tea and I’m back out on the ward again. Three months later my manager asks to see me in the office. ‘What have I done wrong?’ When anyone asks for you to come to the office, its usually bad. They ask if remember the surgical patient who arrested a few weeks back. Of course, I do. I had been thinking about it ever since. I had been worrying about it. I felt it was my fault. They tell me that the case is going to the coroner's court and I was to be called as a witness. I cry. That’s me done then. I’m going to be struck off. I’m going to be found out that I am a rubbish nurse. My manager was amazing. They had experience in these hearings. They explained the whole process. From what would happen from now until the end of the hearing. That afternoon I was contacted by the Trust investigation team. They were lovely too. They asked me exactly what happened and help me write a statement. They put me at ease. It was made clear that what happened was not my fault and that they want to find out what happened to prevent it happening again. The next week or so I had contact with the Trust legal team. I had never spoken to a legal team before in my life. I did feel as if I was a criminal at first. The legal team were also brilliant. They spoke through the actual process; who was in the room, the layout of the room, what questions I might be asked, what the outcomes often are. They gave me advice on how to answer questions; answer what you know as fact, not opinion. If you don’t know, say you don’t know. Be honest. I had two further meetings with the legal team and the investigating team. This was to check I was ok, to make sure I was supported. For what could be an extremely stressful period of my career, was made so much easier by people taking the time out just to check I was ok. I carried on working throughout this period and working with confidence. The hearing came. I knew what to expect. I knew the layout of the room. I knew the patient’s relatives were in the front row, I knew I had to swear an oath, I knew I had support from my Trust. I was able to speak freely – even the bad bits; no covering up or making excuses for others. I was asked what happened that day. I was honest. I didn’t know what was going on. I didn’t know what was wrong with my patient. I was not used to caring for surgical patients. Admitting that I ‘didn’t know’ was awful. I should know, shouldn’t I? When I was saying this, I could feel the eyes of the patient's widow bore into me. I had let my patient down and I had failed. The coroner asked me many questions related to escalation of care to seniors, the policy, my adherence to the NEWS policy – to which I had followed. My part was over in a flash. The next was the surgeon, who got most of the grilling. Why was he not there, where was his documentation, why did he not come when asked repeatedly? It wasn’t his fault either. He was in theatre with another patient. He can’t be in two places at once. I felt really sorry for him. I hope he got the same support I did. The outcome of the hearing was to issue a regulation 28. This ensures that a report is sent to the government by the Trust as the coroner believes that action needs to be taken can to prevent future preventable deaths. So, what happened then? I went back to work and carried on as usual. The ward where I worked no longer takes surgical patients. They made a new unit called the ‘surgical assessment unit’ where surgical nurses care for this cohort of patients. I wanted to share this – yes, there are many issues surrounding this, but the point I wanted to get across is that the investigation team, my manager and the legal team supported me through this difficult time. I am not sure if other Trusts have this level of support for staff attending coroners court.

In this article on The People Space, Megan Reitz, professor at Hult International Business School, outlines the TRUTH framework to help individuals, teams and organisations unpick their conversational habits and to both 'speak up' and 'listen up'.

This infographic, by patient Jennifer Gilroy, demonstrates what makes patients feel safe and what contributes to them feeling unsafe in a hospital environment.

Speaking up, raising concerns, whistleblowing. However you describe it, we know it can be daunting. Supporting 'National Speak Up Month' , the General Medical Council (GMC) has provided advice and tools to help you. What will I learn? Organisations who can support you. Practical tools and advice. Raising concern externally. Advice and reflections from the front line.

During the covid-19 pandemic trainees may be asked to work in unfamiliar environments. Abi Rimmer asks experts how doctors can deal with the change

This lecture, presented to staff at Southport and Ormskirk Hospital NHS Trust on 26 March 2020, gives an overview of the coronavirus, transmission, symptoms and treatment of the virus. Martin Kiernan qualified as a Registered General Nurse in 1984, and obtained a Master in Public Health in 1997. He currently works as a Nurse Consultant where he is responsible for the infection prevention and control programme for an integrated healthcare provider NHS Trust covering acute and primary care. He manages a team of two specialist nurses, a surveillance nurse, a healthcare assistant and an information officer. A significant part of his clinical duties includes assessment and application of policies and guidelines to ensure optimal clinical practice.

This webpage has been developed by 'Sam' a new nurse in the Intensive Treatment Unit (ITU). Here, you will find useful aide memoirs, practical tips and hints on how to get a head with nursing on the intensive treatment unit. ITU handover Bedside checklists Transducing arterial lines Arterial line sampling Bedside monitoring Observations Ventilation basics Activity sheet. About the author Sam is a registered nurse who works for a Trust on the South Coast of England

As part of its commitment to supporting the third sector, The King’s Fund works in partnership with GSK to run the GSK IMPACT Awards, which provide leadership development and funding for award winners. In this blog, David Naylor, a senior leadership consultant at The King’s Fund, reflects on ‘imposter syndrome’, considering its impact on third sector leaders and beyond.

A team of ward nurses from Merseyside took part in the 2018–19 cohort of the Innovation Agency's coaching for culture programme. The team, led by ward manager Sharon Mcloughlin, were all from the Dott Ward at The Walton Centre NHS Foundation Trust, a specialist trust in north Liverpool dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services. What we did Sharon Mcloughlin, Ward Manager, Dott Ward: "The Innovation Agency gave us the dialogue to engage with staff and address concerns objectively, without staff taking anything personally. I was able to say this is an outside organisation, and with them we’re going to look at how our team could improve." “It’s been about empowering staff, and staff realising that change has to come from all of us. I’ve gained skills to help staff feel more empowered and get on board, and see it as their responsibility to improve things too." “Hopefully as a result we’ve improved safety for patients as well. I’m more confident now that I know everybody on the team knows which patients need turning, which patients are at risk of a fall, which patients are suffering from an infection – and if staff don’t know, they need to take some accountability for that now.” Kate Wallworth, Sister, Dott Ward: "After the Coaching Academy we've now got a structure in place – we’re organised, very organised. We introduced our Safety Huddle where all staff come in and listen while we run through all the main points on the ward. That’s before every shift. Going forward everyone is aware of what’s happening on the ward that day. If a visitor comes onto the ward, any member of staff would be able to answer their questions. We all know which patients are suffering from an infection, which patients are going into theatre. It just helps the running of the ward. It’s a more pleasant ward to work on.” Lisa Clark, Sister, Dott Ward: "We had to try and figure out a way to measure if teamwork was improving or not. We introduced a simple box where staff can post a smiley face or an unhappy face, or a comment card – it was just trying to make it as easy as possible. At the beginning we’d see a lot of sad faces going into the box and not many suggestions." “Now it takes me longer to type up because there’s so many suggestions. People mention staff who’ve really put themselves out to help out, just to say thank you. You can see a lot more positive feedback, and everyone who sees their name on the board gets a positive feeling." “I don’t think people realise how powerful and uplifting it is to hear how to be positive – that there is a way to think positively, and there are solutions to problems. That’s something we’ve tried here with the team – if things aren’t going in the right direction, why don’t you think of an idea? How could you fix it yourself?” The Coaching Academy The Innovation Agency’s Coaching Academy is a programme that enables health and care professionals to improve culture, quality and safety of health and care through structured, focused interactions. Coaching for a safe and continuously improving workplace culture is a one-year programme for clinical teams focused on developing safe, high-quality and compassionate services. The programme includes accredited coaching training for team leaders; a collaborative action learning programme with other teams, creating a community of practice; an accredited team culture diagnostic to identify key areas of focus; and quality improvement and innovation practical knowledge and skills.

Everyone should be treated with dignity and respect at work. Bullying and harassment is unacceptable and constitutes a violation of human and legal rights that can lead to criminal prosecution and civil law claims. Employers have a duty of care to provide a safe and healthy working environment for their staff, and this is an implied term of every contract of employment. Bullying and harassment undermines physical and mental health, frequently resulting in poor work performance. Possible consequences include: insomnia and inability to relax loss of confidence and self-doubt loss of appetite hypervigilance and excessive double-checking of all actions inability to switch off from work. This guide is designed to help people experiencing bullying and harassment at work. It covers: What is bullying? Examples of bullying What is harassment? What to do next The legal position Mediation and counselling Employer responsibilities Best practice for employers Students: being bullied whilst on placement Cyber bullying Sickness and work-related stress Been accused of bullying and/or harassment? Witnessed bullying? Further information

This leaflet by NHS Employers (Wales) explains what bullying in the workplace is, how it can affect people and what to do about it.

Back in January 2019, we started a regular team newsletter. Initially this was aimed at only the critical care unit (CCU) team; however, very quickly it developed into an all trust audience.  In this post I discuss the multiple benefits the newsletter has offered as well as the challenges I came across. I want to share my experience on developing the newsletter to encourage other teams to consider writing a regular newsletter if they don’t already have one. This followed on from several outreach teams contacting me personally for assistance in writing their own newsletters.  Our Critical Care Outreach Team (CCOT) work regular shifts within the CCU and our new high dependency unit (HDU). I believe we are not alone, but at times there is an element of divide across the teams and we wanted to limit the ‘them and us’ culture. Even when we are not working within the units, we need effective teamwork to maintain best practice and, ultimately, patient’s safety. Unlike some trusts, our outreach, CCU and HDU are all managed as one big team. With this in mind, we brainstormed ideas for the reasons behind this ‘divide' and decided a regular newsletter might help us. The initial benefits would be: To keep CCU/HDU staff up to date with our current projects - this was a problem identified during recruitment into the outreach team as CCU staff suggested that they had limited opportunity to become involved in the work of the outreach team. Having the CCU staff become more involved and aware of the ‘extra’ work we do has helped to improve our working relationships; various nurses are now more involved with some of our projects, and others are looking to help with the view of progressing into a future outreach role. To explain our role as it not always widely understood by some colleagues on CCU. To offer our support to any individual wanting to work on a QI, but was not sure how to proceed. To highlight our achievements and hard work and to introduce staff to some of our ‘behind the scenes’ work. To involve all staff - we regularly asked staff for suggested content that they would find most useful. The success of the newsletter quickly led us to adapt it to all hospital staff of any discipline or grade: The above benefits were similar, but now pertinent to a larger audience, including healthcare assistants, students, physios, occupational therapists, speech and language therapists, doctors and management. Some of our team are relatively new and it is a good tool to introduce them, using photographs to help improve our visibility and approachability within the hospital. We wanted an ‘educational hot topic’ to be a regular feature to help maintain high quality care and standards amongst staff. We asked readers what topics they wanted to engage with. We now have a number of ‘guest writers’ for this section, from various specialties, to help share their knowledge and expertise. It is encouraging to hear how healthcare assistants, students and associate practitioners have found our newsletter content so educational and helped them to provide better care to the patients (and feel more engaged with the care they are providing). Every time a new edition of the newsletter is sent out, I have received personal feedback of how useful and interesting it has been. Staff have often personally thanked me on the wards and in the corridor. There is a lot of effort and time that goes into these newsletters, but I feel it is definitely worthwhile. I am a great believer in valuing staff and this has really helped me to keep going, despite the difficulties encountered. The newsletter is now jointly written with our Hospital Out of Hours (HOOH) team. Although we are two separate teams, our lead, Rhona, is shared. We all work very closely, supporting each other and preach many of the same messaged, so this just made sense. Challenges and lessons learnt: Team engagement – not all team members wish to be involved in the newsletter and feel there is little extra time to engage with this extra workload. The time spent writing and editing is significant and cannot be done within my working hours, so much of this work has been in my own unpaid time. I have to rely on some sections being written by other professionals. It is difficult to quickly replace sections if deadlines are missed or not already within a requested word limit. I initially edited the newsletter in Word, but found formatting was very difficult. I discovered Publisher and taught myself to use this. I am sure I can learn much more, but have so far found this much easier to work with. We wanted to send to ‘All email users’ within the hospital, but were told this was not possible. Instead, I use various groups of staff set up on our work email system. My first Ward newsletter was only sent out to CCU staff and Ward Managers. This was not always shared with other staff; inboxes were frequently full and therefore emails could not be received; and this method missed vital teams such as physiotherapists, speech and language, doctors, students. Following my distribution issues, I have since compiled a ‘mailing list’ which I add to regularly (this includes professionals in other trusts who enjoy our newsletter too). The hospital librarian team and individual keen students have personally asked to be added to this list which is encouraging. Perhaps we could all share our newsletters and stories within our trusts and on the hub and support each other in this patient safety initiative. I’d love to hear from others on ideas for newsletters and how they have overcome some of the challenges I describe above. CCOT Newsletter to WARDS FEB 2019 Edition 1.pdf CCOT Newsletter for ITU Staff Edition 1. Feb 2019.pdf Joint CCOT and HOOH Newsletter 2nd Edition June 2019.pdf

The first global experts’ consultation for the development of the WHO Leaders Guide on Patient Safety and Quality of Care in Service Delivery took place 20-21 March 2014. Over 25 experts from around the world in the areas of health care management, financing, patient safety and quality of care gathered at WHO to address the global need for strengthening leadership capacity to deliver safe and quality health services. A draft Leadership Competencies Framework on Patient Safety and Quality of Care was developed by WHO through a literature search and analysis of findings, which was debated by participating experts and formed the basis for: technical discussions during the consultation; agreement on the competencies necessary for enhancing leaders’ capacity to prioritize and direct the delivery of safe and quality health services; agreement on the learning topics/chapters and content of the Leaders’ Guide. The Framework identifies the competencies and areas necessary for organisational leadership and management of health services, acknowledging there should be a balance between three domains: Personal attributes. Core functions of leadership: competencies relating to a leader’s ability to set direction and know how to prepare an organisation for safe and effective service delivery. Ability to ‘Execute’/Mise-en-place: competencies relating to a leader’s ability to create enabling environments, systems, processes and mechanisms, and to empower people for delivering patient-centered, quality and safe services.

The Dignity in Care campaign was launched in November 2006, and aimed to put dignity and respect at the heart of UK care services. The Dignity in Care campaign is led by the National Dignity Council, it operates as a charity, inspiring people to be part of a nationwide movement of champions, working individually and collectively to promote access to dignity as a human right for all.  Before the Dignity in Care campaign launched, numerous focus groups took place around he country to find out what Dignity in Care meant to people. The issues raised at these events resulted in the development of the 10 Point Dignity Challenge (now the 10 Dignity Do's). The challenge describes values and actions that high quality services that respect people's dignity.

Healthcare information technology procurement is critical for healthcare organisations, as procurement decisions on medical devices and IT infrastructure will impact safety, efficiency, staff and patient experiences. In this webinar, Svetlena Taneva, from Healthcare Human Factors, University Health Network, discusses using Human Factors in hospital technology. The webinar covers: human factors pitfall of hospital procurement usability testing task efficiency examples of good and not so good design.

Presentation slides from Salford University's Patient Safety Conference. Topics include human factors, learning from deaths, neonatal and maternal patient safety, patient safety in primary care, medicines safety, safety in social care and patient engagement. 2. Master Slides (3).pdf AC_Salfordsafety_primary_care (1).pdf CW - Salford Apr 2019.pdf JH - Meds Safety Salford.pdf MT - Maternal and Neonatal Health Safety Collaborative Break out session.pdf Ursula Clarke PSP Patient Safety April 2019 final.pdf VC - Salford University Patient Safety Conference Glos_ Hosp_ Workshop_ 23 _April _2019.pdf

In this series 'e-Patient Dave' deBronkart shares what we all need to know to get the best medical care without going broke or getting killed in the process. An 'e-patient' is someone who is empowered, engaged, equipped, and able, who never expected the system to do everything but thinks and acts like a responsible independent person. What can I learn? Introducing power of the patient Tricky conditions: understanding disease, diagnosis and decisions What everyone should know about getting the best care The patient's side of the call for better