The safety of our patients is our highest priority. The Trust has a dedicated team who respond to any patient safety incidents, coordinate investigations to learn what happened and ensure that we learn and improve as a result.
We have recently introduced a revised investigation training programme and will be rolling out Duty of Candour training to ensure our staff are equipped to offer a clear and empathetic apology to patients and their families if things go wrong.
In the event of a serious incident, a Patient Safety Response team visits the patient to apologise for any harm or distress that may have occurred, provide help and support for the patient, their relatives and staff, and collect information about what happened. This is followed by a thorough investigation to determine the causes of the incident, and a Learning Team, who identify ways of making the area or process safer.
Learning Teams are facilitated workshops where frontline staff examine existing ways of working to find actual or potential safety issues and fix them. They are used to identify issues, errors and excellence and are now an integral component of serious incident investigations. As well as empowering and enabling all of our staff to get involved in improvement, they also allow us to use safety incidents as a trigger for organisational learning.
We have introduced Safety Huddles across the Trust. Staff meet daily to discuss recent incidents, improving feedback and engagement. We disseminate a “Weekly Safety Message” Trustwide, which is discussed at departmental meetings and safety huddles. As part of the Learning from Excellence campaign, we will be introducing positive reporting across the organisation in 2018 to encourage our staff to share best practice and outstanding examples of care.
We are very proud of our improvement work for Patient Safety across the Trust, and we continue to share our success and learning locally and nationally. The organisation was shortlisted at the National Patient Safety Awards in 2017 in two categories for its improvement work on patient safety.
Human Factors is a scientific discipline that examines the issues and challenges that people can have interacting with equipment, the environment and other people in complex and challenging environments such as hospitals. The Trust has had a Human Factors programme since 2016, which has introduced new team working and communication tools, improved safeguards for clinical procedures and trained hundreds of staff in how to work as part of safe healthcare teams.
In 2014, UHCW joined the national Sign up to Safety campaign, which aims to make the NHS the safest healthcare system in the world. After an initial three-year programme focused on specific pledges, the national campaign has now moved to address safety culture by facilitating open and honest conversations about safety. Developing a culture where staff feel empowered not only to have these conversations, but also to develop solutions for addressing the issues they identify, is a key component of all ‘ultra-safe’ industries and an important part of the Trust's journey towards becoming a world class healthcare provider.
Starting Spring 2018 the Trust is introducing new, automated medicines cabinets and created a best practice injectable medicines practice guide. A Medicines Safety Officer has been appointed to drive the medicines safety and learning agenda.
We have a dedicated Improvement and Innovation Team, and have established a Trust Innovation Hub which provides staff with the space and time to collaborate with each other on new initiatives.
We have introduced a red blood cell calculator app to reduce inappropriate blood transfusions
We have significantly increased the Safeguarding team in order to ensure children, young people and vulnerable adults receive the care and support they need. The trust is in the process of integrating a Child Protection Information Sharing System across the region.
Our Trust Board members conduct regular safety walkarounds and our Executive Directors are buddied with clinical groups, offering coaching, mentoring, support and visibility.
We were the first Trust in the country to introduce the ReSPECT process, which helps ensure that patients’ decisions about the care they want to receive towards the end of their lives are clearly communicated to the healthcare team looking after them. This tool is now being rolled out across the country.
We have replaced all of our beds with new ‘ultra-low’ models that allow patients at risk of falling out of bed to be safer. The “Bay Watch” initiative allocates a member of staff within the patient bay area to manage patients at high risk of falls and anticipate their needs. These improvements have helped lead to 25% reduction in harm from falls and a 10% reduction in all falls.
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