Patient Safety Priorities

Accordion

The final group relates to patient safety.

Click on each of the titles below to learn more and then vote for which of the three you think we should prioritise.

Why is this a priority?

As part of the national Patient Safety Strategy that was introduced in 2019 (and updated in 2021), significant changes to the way in which patient safety incidents are responded to were outlined.  One of the key changes included the implementation of the Patient Safety Incident Response Framework (PSIRF).  PSIRF has multiple elements, and it is likely to take time to implement, so a range of them have been selected as priorities for 2023/2024.

What are we going to do?

  • Fully introduce After Action Reviews (AARs) following patient safety incidents as a means of identifying what happened, what should have happened, what the learning was and an action plan describing how to mitigate risks of it happening again.  AARs will also be able to identify learning from examples of good practice.
  • Introduction of thematic reviews for the highest reported incident categories.
  • Development and introduction of Patient Safety Incident Investigations (these replace the previous Serious Incident investigations).
  • Development of reporting templates to provide assurance regarding quality to the trust board and our ICB.
  • Review and improve how patients/their representatives are involved in the investigation of incidents involving them.

Why has this been chosen as a priority?

When an older patient is admitted into hospital, physiological, physical and psychosocial changes commence within 24 hours of bed rest that affect their ability to undertake normal activities like walking and making a cup of coffee.

Evidence suggests:

  • Hospitalised patients are 61 times more likely to develop disability normal activities than those not hospitalised.
  • 17% of older medical patients who were walking independently two weeks prior to admission needed help to walk on discharge.
  • 60% of patients placed on bed rest have no documented rationale for this decision
  • 50% of patients experience functional decline between admission and discharge
  • Deconditioning contributes to delayed discharge in more than 47% of older patients

What are we going to do?

We will work alongside a national initiative led by the Emergency Care Improvement Support Team (ECIST) as part of #ReconditionTheNation.  We will undertake some focused work to support older frail people to recondition while they are in hospital.

Why this has been chosen as priority?

The WHO Safety Checklist is a mandatory tool and should be completed to ensure that any improvements recommended from the audits are taken forward. All the monthly results are used to produce an annual report. However, it has been identified that the audit forms presented for analysis don’t all match the WHO surgical safety checklist in the notes.

What are we going to do?

We already perform monthly WHO audits of areas using the surgical checklist and a monthly summary is produced and circulated.

There are also Live WHO audits where specialties are being asked to perform at least two per year in their area. This has not been achieved in all areas. This involves a person from another area observing practice, making notes and suggesting ways where practices could be improved. These are reported at bimonthly WHO meetings and are included in the annual WHO report.

We intend to increase the checking of the audit forms submitted against the WHO forms in the notes. This will be an unannounced check carried out two to three times in the year to ensure there has been an improvement in submissions.