Patient safety seminar
Hester Wain, Head of Patient Safety
Anne McDonald, Carl Waldmann, Emma Vaux, Marianne Sampson,
Stathis Altanis
Trust Executive sign up to Patient Safety
What does Patient Safety mean to us?
Dr Emma Vaux: Doing the right thing in the right way every time
for every patient; treating and caring for every patient as if
they were my mother/father/sister/husband/child
Anne McDonald: Doing the
right thing for every
patient every time
Dr Carl Waldmann:
Prevent unnecessary harm
Dr Hester Wain: Ensuring that we have quality processes
that help staff to avoid making errors, so that we
protect our patients and keep them safe
Our Patient Safety Aim
 To provide safe, personal, and professional quality of care every time
for every patient, by reducing the rate of harm and death by 50% by
2012, as measured using the trigger tool.
How can we do this?
 Work harder
 Learn more
 Do better
 Remember everything / Forget nothing
Does this work?
Quality Priorities 2011

Providing a positive patient experience by
improving communication to inpatients,
outpatients, and where appropriate to
family and carers, particularly during the
discharge process

Further reducing the numbers of patients
who develop Clostridium difficile infection
while in hospital

Improving care for patients with dementia

Reducing harm and mortality from VTE
(blood clots), falls and sepsis
RBFT
Campaign for Preventing Harm,
Board Leadership/
Executive Walkarounds
Mortality Reviews
Patient Stories
Care Bundles
Infection Prevention &
Control
Reducing Harm from
Deterioration
Global Trigger Tool
Medicines Management
Monthly Hot Topics
Call 4 Concern
Productive Ward
Patient Safety Council
Patient Safety Federation Workstreams
Patient Safety First Campaign for England
Measurement for Improvement
Education & Training
Improving Safety
PDSA
Plan - the change to be tested or
implemented
Do - carry out the test or change
Study - data before and after the
change and reflect on what
was learned
Act - plan the next change cycle
or full implementation
Improvement process 1
 Identify area where patient safety is at risk, by
looking at complaints, incidents, audit reports
ACT
STUDY
PLAN
DO
 Create a process map of what actually happens
on the ward
 Develop ideas for change eg borrow innovations from other trusts, find
published interventions, follow hunches, collate staff ideas
 Work out how to measure success with “metrics”:
– immediate process measures (is the new idea being used)
– trustwide outcome measures (is the new idea creating safer care)
– remember to add balancing measures (does this new idea alter
something else for the worse)
Improvement process 2
 Pick one area for a small step of change eg write procedure, change
procedure, write a checklist, use different staff/new equipment
 Set up PDSA cycle with small defined group/area/ward with friendly
staff who are committed to give it a go. Measure and record process,
outcome and balancing metrics for a short time period eg 1 week
 Repeat PDSA cycles to get improvement, and record each change,
some will be useless, do not be afraid of failure this is a learning
process!
 Change needs to be 95% reliable. The best test of this is to ask 5
people on the ward how to do it, if they can all tell you, the process
improvement works.
 You need a working process that is 95% reliable, before you
disseminate the change further.
ACT
STUDY
PLAN
DO
Neutropenic sepsis
February 2010: 81% of antibiotics administered within 1 hour
% patients receiving IV antibiotics
within 1 hour
100
81
80
60
40
20
Consultant Champions in
ED, CDU, Oncology &
Haematology
Cancer electronic patient
record system (RDS)
access available in CDU
19
0
Jan
Feb
ACT
PLAN
STUDY DO
Neutropenic sepsis
August 2010: 94% of antibiotics administered within 1 hour
Telephone line for
patients discharged from
CDU/ED
% patients receiving IV antibiotics
within 1 hour
100
91
81
80
Follow up by CNS
94
93
82
76
60
Monitoring of stat. doses
of antibiotics in patients
who are not neutropenic
and not septic
40
20
19
Au
g
Jul
Jun
Ma
y
Ap
r
Ma
r
Feb
0
Jan
Audit of quality of
advice/information given
ACT
PLAN
STUDY DO
PDSA cycle for Walkarounds
Plan
 Set-up system for weekly Patient Safety Executive Walkarounds
Do
 Visit ward areas with Executive Team
Study
 Number of walkarounds – weekly rota maintained but challenging
 Actions – resource intensive logging and report write-up
 Feedback – all ward staff thanked, positive feedback included in report
Act
 Weekly rota now coordinated by assistant
 Actively delegate actions during walkaround
 Include feedback in summary reports to Exec
PDSA cycle for Walkarounds
Plan
 Develop Patient Experience Executive Walkarounds
Do
 Amended paperwork, reviewed staff (added Matrons & PALS), visit ward areas
with Executive Team
Study
 Patients and family keen to talk – often challenging to talk to more than one in the
visit
 Actions – written up by each staff member with 3 key points
 Feedback – given directly to ward at time to facilitate any problems identified
Act
 Include these patient stories in Board Committees
Practising with PDSAs
 4 facilitated workgroups
 Patient Safety topic options are:
– Diarrhoea
ACT
STUDY
PLAN
DO
– Falls
– Pressure ulcers
– Blood clots (VTE)
 Review the information and discuss what system changes may reduce
harm and increase safety
 Identify one small change and create a plan to implement this
 Feedback to all workgroups
Our Patient Safety Aim
 To provide safe, personal, and professional quality of care every time
for every patient, by reducing the rate of harm and death by 50% by
2012, as measured using the trigger tool.
How?
 Identify the issues
 Develop the solutions
 Try small steps of change (PDSA)
 Measure the success
 Disseminate the practice
 Monitor sustainability
Care Bundles
HSJ Patient Safety Award, November
2010
Getting it right for every patient every time:
Timely antibiotics for patients with
Neutropenic Sepsis
Nursing Times & HSJ Patient Safety Award,
March 2011
Patient Safety in Critical Care: 'Call 4 Concern'
helpline