Patient Safety Learning

Patient Safety Partners: what does good look like? The Patient Safety Partner (PSP) role introduced by NHS England as one of two key strands of its 'Framework for involving patients in patient safety'. PSPs can be patients, relatives, carers or other members of the public who want to support and contribute to a healthcare organisation’s governance and management processes for patient safety. In April 2024 we jointly held a workshop with Advancing Quality Alliance (Aqua) focused on the implementation of the PSP role in the NHS and the question; “what does good look like?”. Attendees included members of the Patient Safety Partners Network (read more about the network here: https://lnkd.in/etme5Adk), national PSPs as well as managers from trusts. Drawing on the insights from this workshop, and reflections from members of the PSPN, we have now published a number of different blogs on this: ▶ Lack of role clarity a barrier for impact: https://lnkd.in/esGVWRRP ▶ Recruitment and induction: https://lnkd.in/etBjMyBD ▶ Influencing for safety: https://lnkd.in/e8rqPCev #pslhub #patientsafety #nhspatientsafetystrategy #patientengagement #patientinvolvement #patientsafetypartners

Our Chief Executive Helen Hughes was quoted in the Observer yesterday on concerns about recent figures showing GP practices make about 400,000 referrals a month to outpatient clinics that are fully booked. GPs typically refer patients to ­outpatient clinics using the NHS e-referral service, which can also be used by the patient to book a suitable appointment. The most recent figures, for July, show there were more than one million appointments booked in England, but 407,173 cases in which no slots were available. Some patients will be able to choose an alternative provider, some will be booked at a later date, but many end up being bounced back to their local surgery. The number of unavailable slots has risen by 78% since July 2018, when the comparable figure was 227,937. There were severe shortages of appointments in orthopaedics, cardiology and diagnostic imaging. In her full comment, Helen said: "It is important that when new patients enter waiting lists that they are prioritised according to clinical need against those already on the list, rather than the system operating on a ‘first come, first served’ basis. Patients waiting for care need to be monitored and reprioritised as their level of need is likely to change as they wait. There is a major question as to who is responsible for ensuring that any patient deterioration while waiting for care is picked up and acted upon. These decisions need to be coupled with clear communications to patients experiencing long waits. This should include open and honest conversations about timescales for treatment, what they can expect to happen and when." She also highlighted that there does not appear to be a system for monitoring the impact on patients and patient safety of such waiting lists, stating: "We know how many people are waiting and for how long, but do we know the impact that is having on their health and wellbeing? How many people are deteriorating, experiencing pain and even dying whilst they are waiting? This is not just a numbers game, it’s about people and the impact on them and their families, for their physical and psychological wellbeing and their ability to live the life they want to." https://lnkd.in/eMhtnqvz #pslhub #patientsafety #outpatientclinics #waitinglist

This year's World Patient Safety Day will be focusing on diagnosis. Find out more about diagnostic safety and how we'll be supporting the event via the hub (free to join here: https://lnkd.in/e3dSDCCF). Read more about World Patient Safety Day 2024 here: https://lnkd.in/e5SSPS2W #WorldPatientSafetyDay #WPSD2024 #patientsafety #diagnosis #diagnosticsafety #diagnosticerror

Featured on the hub this week, a study presenting initial findings of a evaluation of the role of Patient Safety Specialists in the NHS. Patient Safety Specialists are individuals in organisations who have been designated to provide dynamic senior patient safety leadership. The creation of these roles was a key part of the NHS Patient Safety Strategy, with all NHS organisations in England asked to identify one or more specialists by late 2020. Key findings from this evaluation included: ▶ From the results of a national survey of Patient Safety Specialists, most respondents (68%) came from a clinical background; half (48%) were registered nurses and 8% had a medical background.  ▶ The study’s findings suggested that many organisations were struggling to resource their patient safety specialists to the extent that specialists themselves would like and that NHS England recommended. ▶ Analysis of data from interviews and focus groups suggested that having a clear link to a board member invested in patient safety was crucial to patient safety specialists’ sense of being supported, and to ensuring that their work was prioritised appropriately. ▶ In the interviews and focus groups, participants noted that, for patient safety specialists to be successful, they needed to act as ‘critical friends’, able to ‘hold a mirror up’ to the organisation while building relationships. Read more below: https://lnkd.in/eVHjGGpE #pslhub #patientsafety #patientsafetyspecialists #nhspatientsafetystrategy THIS Institute (The Healthcare Improvement Studies Institute) Robert Pralat Justin Waring PhD FAcSS FRSA Tara Lamont Helen Hughes

Mind the potholes! Implementing After Action Reviews. Remember the last time you drove down a road full of potholes? Avoiding the hazards they create—burst tyres, damaged suspension and under-carriage—is like a healthcare organisation navigating potential pitfalls when implementing the learning response tools in the Patient Safety Incident Response Framework (PSIRF) toolkit. Using the potholes metaphor, the National After Action Review (AAR) Reporting Template Team share their reflections on implementing AAR and its challenges: https://lnkd.in/eYYu8CqB #pslhub #patientsafety #patientsafetyincident #PSIRF #patientsafetyincidentresponseframework #afteractionreview #swarmhuddle #organisationallearning #organisationalculture Tracey Herlihey Jane Carthey Melanie Ottewill Judy Walker Gabby Walters

Are you passionate about improving patient safety? Would you like to share your insights in an article or blog on the hub, our award-winning platform to share learning for patient safety? Find out more by taking a look at our blog writing guide: https://lnkd.in/e4uf-bpT #pslhub #patientsafety #blogwriting #healthcommunication

𝗣𝘂𝗯𝗹𝗶𝘀𝗵𝗲𝗱 𝘁𝗼𝗱𝗮𝘆 - Patient Safety: Emerging Applications of Safety Science: https://lnkd.in/eKK7X_Pf There are few resources and books for professionals within the patient safety sector that use case studies to model the practical application of theories of patient safety incident investigation. Exploring these theories, this new book brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help you understand some of the emerging theories of safety science and their practical application. It is written by people who work in patient safety, and with chapters on subjects such as System Engineering Initiative for Patient Safety (SEIPS), AcciMaps and Human Factors, this book is for everyone with an interest in how the landscape of patient safety is changing and how to apply good practice for the reduction of avoidable harm. #pslhub #patientsafety #humanfactors #accimaps #seips #patientsafetyinvestigation #psirf #afteractionreview #safetyII #patientengagement #familyengagement #changemanagement #simulation #thematicreviews Jordan Nicholls Helen Hughes Julie Storr RGN BN MBA MHS Paul Bowie Helen Vosper Mark Sujan Judy Walker Jayne Wheway Phil Gurnett Sharon Marie Weldon Ken Spearpoint Andy Buttery Dr Samantha Machen Class Professional Publishing

Preventable negative hysteroscopy experience - a new patient blog featured on the hub this week https://lnkd.in/exxDCfVP #pslhub #patientsafety #avoidableharm #hysteroscopy #womenshealth #informedconsent

Surgical fires and burns: The untold stories and efforts for prevention. Imagine waking up after surgery and not only dealing with the pain and stress of the procedure itself but also with the added trauma of severe burns. This nightmare scenario is a reality for some patients who have caught fire undergoing surgical procedures within the perioperative environment. The Surgical Burns Action Group is working to change this. In a new blog on the hub, its chair Lindsay Keeley shares with the hub the Group's mission and key initiatives: https://lnkd.in/eZ33HE2u #pslhub #patientsafety #avoidableharm #surgicalburns #surgicalfires #safersurgery The Association for Perioperative Practice (AfPP) PLMR Healthcomms

With rising waiting lists, system-wide workforce challenges and significant financial constraints, the NHS is facing the most severe pressures in its history. In this error-provoking context, it is essential we don’t overlook patient safety; preventing avoidable harm is now as important as ever. At this critical moment, we are partnering with Public Policy Projects to deliver a new programme of work with the aim of embedding patient safety as a core priority across national and local health systems. The programme, Harnessing technology to enable a system wide approach to patient safety, will bring together health system leaders, industry experts and patient/end-user representatives to discuss patient safety through the lens of technology, digital innovation and data-driven transformation. Read more on our website below: https://lnkd.in/eqQuqHSf #pslhub #patientsafety #digitalhealth #safetydesign #healthtech #digitalinnovation