Patient safety

Patient safety is fundamental to the provision of high-quality services and is defined by NHS England as:

"Maximising the things that go right and minimising the things that go wrong for people experiencing healthcare."

The impact of patient harm is felt widely by patients, families, loved ones and the teams delivering care.

Our vision is to embed a culture of patient safety across the Trust and across pathways of care. We are aiming for our staff to have an environment in which they can consistently understand factors that impact on:

  • patient safety
  • collaborate
  • support innovation
  • share learning in relation to patient safety across the Trust and with patients, carers and wider agencies and partners

We acknowledge that there has been a fear of blame within the NHS and we want our staff to fee safe:

  • to report incidents without fear of reprisal
  • to question practice or resources
  • in their daily work

We recognise that our staff are our greatest asset. We are committed to developing a culture of learning, transparency and openness that enables us to continue to develop patient safety and make the Trust a great place to work in health and social care.

Patient safety partners: Involving patients in patient safety

The patient safety partner is a new and evolving role in the NHS that aims to empower patients and carers.

Here at the Trust, we are excited to welcome a team of patient safety partners to work alongside our staff, patients, and families to influence and improve safety within our hospitals and community services.

Patient safety partners can be patients, carers, family members or other lay people (including NHS staff from another organisation).

Framework for involving patients in patient safety

In June 2021, the ‘framework for involving patients in patient safety’ was published by NHS England. This framework sets out approaches and standards that help to make a positive difference to how patient safety is viewed and managed in the NHS.

A key part of the framework introduces patient safety partners; empowering patients and their carers to be involved in their own safety. As well as being partners alongside staff in improving patient safety in NHS organisations.

Role of a patient safety partner

The main role of the patient safety partner is to ensure that the patient voice is heard within organisations, with the core purpose of improving safety and quality. The following are examples of work that patient safety partners would be involved with:

  • membership of quality and safety committees
  • review and analysis of safety related information
  • involvement in patient safety-related projects
  • participation in investigation oversight groups

Our patient safety partners will be fully supported in their role and will be provided with ongoing supervision and support. They will also receive training, so they are best able to support patient safety across the Trust.

Recruitment

We are actively recruiting 4 patient safety partner roles across our mental health, adult community services, learning disability and children’s services.

If you are interested, contact Kerry Crowther, Patient Safety Specialist. Call 07920 757 327 or email Kerry Crowther.

Resources

Patient safety incident response framework

The Trust as an early adopter of the patient safety incident response framework, has developed alongside key stakeholders a patient safety incident response plan which sets out how we will respond to patient safety incidents reported by staff and patients, their families and carers as part of work to continually improve the quality and safety of the care provided.

The plan sets out the ways the Trust intends to respond to patient safety incidents to learn and improve through patient safety incident investigations and patient safety reviews.

Patient safety incident investigations

The Trust has identified the following events that we intend to investigate selected cases through a patient safety incident investigations:

  • self-harm incidents for patients under 25 years of age and receiving support from community mental health services
  • unwitnessed falls for patients over 80 years of age admitted to our adult inpatient wards
  • category 2 or unstageable pressure ulcers developed in the community while receiving care from both district nurses and another care provider
  • delay in initial start of treatment following referral for children and adolescent mental health service (CAMHS) with moderate or severe mental health conditions
  • interruption in continuity of community nursing care where the team was unable to provide treatment or support as planned or expected
  • complications in transition of care for a young person with a moderate or severe mental health diagnosis transitioning from CAMHS to adult mental health services

Resources for additional patient safety incident investigations has also been allocated for any significant unexpected trend in incidents that could not have been foreseen as part of this planning exercise.

We would also undertake a number of patient safety incident investigations on national priorities which include:

  • never events
  • incidents that meet the learning from deaths criteria
  • death or long-term severe injury of a person detained under the Mental Health Act
  • domestic homicide

Deaths that had previously been investigated as serious incidents under the 2015 framework will be reviewed in line with the learning from deaths national priority, during the review process certain incidents may proceed as a patient safety incident investigation.

In the years ahead, the Trust will seek data and insight from stakeholders to inform potential future categories for local patient safety incident investigation and system improvement.

Patient story videos

NHS England have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient

Kathryn’s story

Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed.

Kirsty’s story

Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip.

Valerie’s story

Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication.