How do we work to improve patient safety?
The podcast with Emma Babski, Patient Safety Manager
Welcome to our weekly podcast, here today to talk to me is Emma Babski, Patient Safety Manager
We have a dedicated Patient Safety Team that works hard to ensure that we avoid unintended or unexpected harm to people when they receive care in our hospitals. Can you tell us more about the team?
Obviously every member of staff works hard to do this! But our team supports them and pushes forward improvements in safety and quality. Part of this improvement is reviewing situations when something has gone wrong or had the potential to go wrong so that we can learn from it. Our hospital promotes an open and honest culture around reporting incidents, the purpose is to identify action to mitigate the risk of similar incidents occurring and to keep our patients and staff safe, we are not looking to blame but to learn.
When and if something goes wrong, does a patient need to informed if it’s about their care?
Yes. This is called the Duty of Candour.
Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that healthcare professionals must:
1. tell the patient (or, where appropriate, the patient’s advocate, carer or family) when
something has gone wrong
2. apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
3. offer an appropriate remedy or support to put matters right (if possible)
4. explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.
Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns.
The patient safety team are here to support staff with having those conversations with patients and supporting them with the investigations into the incidents, we also give the patient to ask question in regards to the incident to ensure that they are involved in the investigation being carried out and we share the out comes with them.
How has reporting incidents changed over time?
We have seen an increase in incident reporting, and this is not because more incidents are occurring, it is because staff are open and honest and understand the importance of learning and mitigating the risk of harm. What we see is an increase in the near miss and no harm incidents which supports implementing actions that mitigate the risk of an incident re occurring which may potentially cause harm to a patient or a member of staff.
So who implements these actions identified following incidents?
We all do, depending on the category of the incident, the investigator will identify learning as part of the investigation.
We hold a bi-monthly root cause analysis training programme which is open for staff to attend, they receive training on how to apply the root cause analysis methodology when investigation incidents to ensure The first goal is to identify and understand the root cause of incident that has occurred
The second goal is to identify and learn from any underlying issues within the root cause / that led to the incident.
Thirdly, actions should be identified and implemented to mitigate the risk of reoccurrence or a similar incident occurring.
So, Root causes are often gaps in processes and systems and very rarely human error. We cannot take human error out of the equation completely. But by better understanding a normal human response, we can prevent human error stepping in and strengthening processes in our hospital support this.
What processes have been changed to improve safety recently?
Processes are changed all the time, there have been some awareness campaigns about improving safety, such sepsis and pressure ulcers, we we’re also always listening to people so that we don't leave them silent.
And there was a direct link and the research is growing and growing and growing about this, about if you look after your staff, then you will improve your patient experience and outcomes.
There was a big campaign a few years ago called sign up to safety, simply focused all the time on this, care for the people that care.
Positivity, joy, kindness, empathy, appreciation, gratitude, compassion, psychological safety and learning from excellence. All of those things impact on, every single day, on the care that is provided and the safety of the care that you provide. Because all of that impacts on the health and wellbeing of our staff. And it is so vital that we deal with these things.
And our first talk also talked about getting the fundamentals right, dealing with fatigue and hunger and the memory loss that goes with all of those things. The distractions that we get all the time.
We want to eliminate the fear of speaking up and recognise staff for the wonderful work they do.
When people are recognised for what they do, they are 23% more effective and when they are appreciated, they are 43% more effective. So if you go around saying, thank you, you’re brilliant, I loved what you did when you sat down with that patient and you told him he had prostate cancer, and that you told it so eloquently and so kindly, and you stopped every few minutes to find out whether he understood what you were telling him and what that meant for him and what treatment he was going through. When you do that, that is amazing, please do that again.
What is the NHS direction of travel in terms of safety?
NHS Patient Safety Strategy…
As part of the strategy is the new patient safety incident response framework which is soon to be announced which will replace the serious incident framework and will further support improving patient safety, The Hospital have recently recruited a patient safety specialist, Ed Cox who will be leading the implementation of this, once the framework announced and implementation plans are underway , I am sure Ed would love to come along to a podcast to talk through the new framework and the exciting changes being implemented across the hospital.
Well it sounds like there are lots of exciting plans in the pipeline to improve patient safety
Yes, we also have patient safety day in September, the Hospital have decided to dedicate the week to this event rather than just a day and will include competitions, quizzes, information stands, online seminars and lots more exciting things. So keep your eyes peeled for more information.
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