PATIENT SAFETY
specialist with the Oxford Academic Health Science Network and patient leader at Royal Berkshire NHS Foundation Trust, outlined what this might look like in practice. “Leadership is vital, because what leaders do permeates the whole organisation,” he said. “Our new chief executive says that the standards you walk past are the standards you accept. Leaders need to be very clear about their beliefs and values and, most importantly, live them. Otherwise, people do not know what they are supposed to do, and what kind of people they should be.” Dr Arun Chidambaram, Mersey Care’s operational medical director, said it was also important for clinicians to be open and to be able to speak up if they saw something going wrong. The Trust has worked hard to create a just culture in which this can happen. In a moving presentation from Jo Hughes, the founder of Mothers’ Instinct, the conference heard what can happen when culture is not open and the patient perspective is not taken into account. Hughes set up Mothers’ Instinct after her 20-month-old daughter, Jasmine, died and she had to “put her grief on hold” while an inquiry and an inquest took place. “Jasmine died because of communications issues that allowed signs of her deterioration to be missed,” Hughes said. “And that is a common factor for bereaved
mums. Poor information flows lead to staff perceptions that are wrong, and that make us think as mums that we are wrong. “Then, organisations do not help us with grief and with creating a legacy for our children. Instead, we are made to feel like our children’s lives do not matter. Our treatment in the aftermath of Jasmine’s death broke my heart all over again.” Action against Medical Accidents also campaigned for patient safety and justice, an in another blog published ahead of the conference,6
chief executive Peter Walsh
outlined what the organisation thinks patient involvement at all levels should look like. “Overall, there is a role for patient engagement at every level of care,” he said. “Patients can help to keep themselves safe, remain engaged if something does go wrong, and contribute their knowledge to patient
Our new chief executive says that the standards you walk past arethe standards you accept. Leaders need to be very clear about their beliefs and values and, most
importantly, live them. Douglas Findlay, Royal Berkshire NHS Foundation Trust
safety initiatives across the system. “What we need is to make sure patients are empowered to speak up, that they get the help and support they need to be involved in investigations, and that their role in patient safety initiatives is planned and funded, so the NHS’ ambitions in these areas are realised – and not just good intentions.”
Systems thinking
Back at the conference, Dr Matt Inada-Kim, a consultant in acute medicine at the Royal Hampshire County Hospital in Winchester
and clinical lead for sepsis/deterioration in Wessex, outlined the practical steps that have been taken across the region to spot when patients are deteriorating and to make sure that it is communicated to clinical teams. The National Early Warning Score,7 known as NEWS2, is now being used as a common language across care settings, he said; and the development of a shared care record, the Hampshire Health Record or Care and Health Information Exchange,8 has helped to make sure that people are aware of the score and its implications. The potential of data was also the subject of a presentation by Alison Leary, professor of healthcare and workforce modelling at London South Bank University, who showed how data collected routinely from electronic patient records and systems such as the Datix incident reporting system, could be used to inform patient safety issues, such as staff numbers and skill mix. However, she pointed out that staffing would look very different if the UK treated healthcare as a “safety critical industry” like the airline or oil industries – which is something that Norway does. In a safety critical industry, she said, the most experienced staff are deployed to deal with the most stressful and difficult issues; while the least experienced do high volume, low risk work under guidance while they learn their jobs. That’s often not the case in the NHS, where junior doctors and staff just out of training are often the first in line.
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