Patient_Safety_Learning

The 11th meeting of the Patient Safety Partners (PSP) Network included:
•    A Patient Safety Incident Response Framework (PSIRF) update from network member Mark Smith
•    A presentation from Francine Franks, Senior Designated Nurse for Safeguarding Adults (presentation slides)
•    Follow up questions and discussion around safeguarding
•    Discussion around sharing member insights in future meetings
•    Update from Patient Safety Learning on the forthcoming blog and the AQUA impact survey.

Please find the full notes attached. 

Patient Safety Partners Network meeting notes 2 July 2024 (1).docx

These are the slides for the presentation given to the PSPN meeting on 2 July by Fran Franks, Senior Designated Nurse for Safeguarding Adults.

PSIRF and Safeguarding July 2024 (1).pdf

Patients are increasingly being asked to access online systems to:

• request prescriptions or make medication requests
• access healthcare records and test results
• make appointments
• communicate health concerns
• sign consent forms.

These developments can have a positive impact but they can also carry potential challenges, as highlighted in this recent blog -  Digital-only prescription requests: An elderly woman sent round the houses.

We'd like to hear your experiences of using online systems in healthcare.

Have they made things easier? Does it feel like your care is more joined up for it?

Have any of these changes been challenging? If so why? 

Comment below (sign up first for free) or contact us directly at content@patentsafetylearning.org to share your experience.

15 hours ago, blueiii said:

Like many others commenting on this site, I too went into my IUD fitting thinking I had high pain tolerance.  I waited over a day to see a doctor about a comminuted fracture in my elbow, not wanting to bother them if it wasn't anything serious.  I knew to expect some heavy cramping, but was ready to face it in order to get the IUD inserted, and took some ibuprofen prior to the procedure to hopefully keep some of it at bay.  I had great interactions with my GYN in past visits, including for a D&C due to uterine polyps.

I also had heard of some people fainting during insertion, but thought that it was more of a reflex due to pressure on the cervix, than something related to pain.  I was well versed in the technicalities of the procedure, she started with an infusion of lidocaine, and I had only slight anxiety about getting it done.  The clamps and infusions weren't bad, nothing worse than the D&C was.

The pain I felt once she started trying to dilate my cervix for the IUD was excruciating.  Excruciating.  Worst by far that I've ever experienced.  Usually when pain gets bad, I get silent, and hold my breath, if anything.  Here I was involuntarily crying out in pain, which I've never done before.  I started sobbing absolutely uncontrollably, unable to think, see or control my breathing.  She was trying to check in with me, but I was so absolutely not in control of myself I couldn't answer.  At one point my GYN paused to let me try to center myself and to give me two rounds of injections into my cervix, but as soon as she started again, the pain was immediate.  She said my cervix was very stiff and she was having trouble dilating it enough to get the probe in.  When she took my hand to try to comfort me, I was sweaty, cold and clammy.  She asked if I wanted to stop and try another day, but I knew if I didn't get it done then, I wouldn't ever come back.  So I tried to grit it out.  I soon was sobbing uncontrollably again once she restarted with the dilators.  I managed to ask her for an honest opinion on how much longer it would be (it had been at least 20 minutes at this point).  I could get through one last push, I thought.  But she wasn't anywhere close to done (she hadn't even gotten the probe in to check for uterine depth), and made the call to abort the procedure.   When she saw my face, she immediately laid the back of the chair back because my face was so white. She had to see her next appointment, so I laid there alone with immense cramping, my legs shaking, and sobbing for another 45 minutes.  I hadn't brought anyone to my appointment, so I had to lay in the grass outside for another hour until my legs stopped shaking and I could control my sobbing, to be safe enough to drive myself home.

How is this acceptable?  I come onto blogs like this and find I am far from the only person who has had this experience.  Trauma, was what it was.  How could I not have been offered even the slightest sedation or any pain medication stronger than ibuprofen?  How do we not know how many women have been equally traumatized by what is described to us as a simple procedure?  My husband was given so much more pain control both before and after his vasectomy.  I have had issues with the health care industry before, but have never felt so absolutely failed by it before.

 @blueiii I am so sorry to hear about your painful and traumatic experience. The points that you and many others have raised, are incredibly important and we refer to this forum when we connect with others in the gynae space, highlighting the need for urgent improvement. 

More recently we have been seeking examples of good practice to share, with the aim of helping others learn from their work to provide safer care. We have also been working with researchers who have been exploring this area. I am including a few links below to content that may be of interest. Many of the issues raised by patients undergoing IUD procedures mirror those we have heard in relation to hysteroscopies. So I have also included a piece we wrote calling for action on that. 

Better data collection, patient reported outcomes and making sure women can have access to all of the available pain relief options (with the relevant information) would be a start to improving things. You'll see from the example in one of the links below that the team in Oxford also have a complex pathway for patients who they identify as having the potential to experience high levels of pain or trauma. It is a flexible system, based on listening to the patient - another key area for improvement. There is so much to learn in this space, to make sure patients don't continue to suffer as you have or lose trust. 

Fitting coils: developing a safe and supportive service

Pain experiences during intrauterine device procedures: a thematic analysis of tweets (11 June 2024)

Coil procedures: Exploring negative experiences through qualitative research (an interview with Sabrina Pilav)

The ripples of trauma caused by severe pain during IUD procedures (BMJ Opinion, July 2021)

Hysteroscopy: 6 calls for action to prevent avoidable harm

On the 10 April 2024 a workshop was held in Birmingham, facilitated by Patient Safety Learning and AQUA. The workshop focused on Patient Safety Partners (PSPs) and 'what good looks like'. Several members of the PSPN attended. 

These are the notes from that workshop. 

10th April Event Report for discussion 100424.pptx

Have you or someone you know been affected by a:

• delayed diagnosis
• incorrect diagnosis
• missed diagnosis?

Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing.

If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at content@pslhub.org. 

The 9th meeting of the Patient Safety Partners (PSP) Network included:

•    an update from Helen Hughes and Emma Walker (AQUA) on the recent PSP workshop
•    discussion on the PSPN chair process 
•    discussion about role related tasks and role clarity
•    Duty of Candour consultation.

Patient Safety Partners Network meeting notes 7 May 2024.docx

Shared with the network by member @Colin Fiske...

We have had a lot of discussions at our PSPN meetings about the role we as PSPs undertake and it clearly varies across each Trust. For us PSPs at the United Lincolnshire Hospital Trust we have been extremely lucky and well supported by the Trust and welcomed wherever we have engaged.

Organisationally we sit within our Patient Safety Team as Line Management, which is within the Clinical Governance portfolio. I thought it might be helpful to share the PSP Handbook we were issued along with the current groups we sit on which I hope you may find informative. We, as a PSP team meet informally with our line management via teams but with a F2F session on a regular basis to discuss how things are going, any issues or equipment needs and changes to the working groups we currently each sit on (these are split across our PSPs). I hope this helps some of you in your PSP role.

I hope this will enable some wider discussions and help support you with your own Trust. 

PSP Meetings-Feb 24.docx Patient Safety Partner Handbook November 2023.docx

Hi @Rich O Connor

Unfortunately from what Hes Wain said at her presentation to the PSPN, they don't currently have those communication channels (to local PSP networks) established. She said there is no list of PSPs, outside of the national team. But we can certainly raise your question and see if this does exist for recruiters of PSPs. 

Some of the resources she shared after her presentation may help too - see link below:

https://www.pslhub.org/forums/topic/407-resources-shared-following-the-presentation-by-hester-wain-and-chris-mcilveen-5-march-2024/

@Mark Hughes @HelenH any thoughts?

Physician associates are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor, providing care to patients in primary, secondary and community care environments.

First introduced in 2003, PAs have become increasingly talked about in healthcare and in the media, with many discussions focused on the safety of the current approach. 

We want to hear from patients and carers. 

• Have you, or someone you care for, got an experience of being seen by a PA that you would like to share?
• Do you feel more information about the PA role would be useful for patients?
• Do you have any other comments, concerns or perspectives you would like to add?

Please comment below (you'll need to sign up first, for free) or contact the team at content@pslhub.org

The 7th meeting of the Patient Safety Partners (PSP) Network focused on a presentation from Hester Wain, Head of Patient Safety Policy at NHSE, and Chris McIlveen, National Patient Safety Partner. Their presentation focused on the Patient Safety Partner role, what they are doing at a national level and the Involving patients in patient safety (IPIPS) framework. This was followed by a discussion focused on the presentation.

The presentation slides and resources mentioned during the session are linked to within the notes (attached below). 

Other points raised, outside of the presentation, included:

• Never Event consultation 
• Patient Safety Partner Workshop - 10 April
• Access issues - emails, the private online network space etc. 

Patient Safety Partners Network meeting notes 5 Mar 2024.docx

An interview published today on the hub that may be of interest:

At the meeting on 5 March, Hester Wain, Head of Patient Safety Policy, and Chris MCIlveen, National Patient Safety Partner gave a presentation to the PSP Network. 

The below links and attached resources have been shared by them following the presentation. 

Patient engagement resources on the NHS England website

• WPSD 2023 - World Patient Safety Day 2023 – engaging patients for patient safety (Various blogs and videos)
• Simple steps to keep you safe during your hospital stay (Video)

Various PSP resources (you will need to be logged into the NHS Futures platform to access these)

• Enabling PSP inclusion and enhancing diversity
• National PSP remuneration and expenses step by step 
• National Patient Safety team PSP FAQs 
• National PSP Mentor Handbook 
• National PSP mentors training and resources guide

Attachments include:

• Presentation at PSPN meeting (slides)
• Patient Safety Partner Mentor’s Handbook
• Involvement Payment and Expenses – a guide for PSPs and patient safety team programme areas
• Patient safety partner frequently asked questions (FAQs)

230802 National PSP FAQs ver 2.3.pdf 20230721 PSP_PPV remuneration and expenses.pdf 20220117 Mentor Handbook.pdf Presentation at PSPN meeting 050324.pdf

On 15/02/2024 at 15:39, Lisa Riste said:

Im on salt tablets for really low blood pressure - without them I keel over. My nominated pharmacy hasn't been able to get hold of stock - bearing in mind I'm on 6 x tablets a day so 168/28 days. I'm feeling lucky if they have 60 at a time.... It takes a huge amount of 'patient effort' to navigate this. Eventually the request lapsed and they couldn't get anymore so GP had to issue paper script and after 7 pharmacies I found one with 96 in stock - so another owing slip.

Im not sure people realise the time implications this has throughout the whole medicines journey? My solution (and please don't try this at home) was to reduce it to 5 per day - plus lots BP checking, then went to 4 per day to try to ensure I had some supply left. I have a BP monitor and had my condition for around 10 years so I know what I'm doing - I couldn't go any lower or my dizzy spells kicked in. I then tried to reorder from GP again - second pharmacy were getting some but dk when.

With 7 tablets left.... scarily close to trying to negotiate with hospital pharmacy to get a cardiology prescription for me, I won the lottery and my nominated pharmacy tested to say they had some in for me. Ive gone back to 5 per day to be on the safe side but am OK now til start of April. 

Daren't even mention HRT patches shortage - only one type I can tolerate due to adhesive allergies. 

Thank you @Lisa Riste for sharing your experience and the related safety risks of patients not being able to access their full prescriptions. Patient insights like yours will help to build a picture of the range of issues faced, and the impact these can have on individuals physical health and mental health. 

The 6^th meeting of the Patient Safety Partners (PSP) Network focused on the following points of discussion:

• PSP survey data.
• Using the collective voice and efforts of the PSPs for change and influence.
• Potential workshop to explore ‘what good looks like’ for the PSP role.
• Leadership and vision for the PSP role.
• Access to the private online area for the network.

Patient Safety Partners Network meeting notes 6 Feb 2024.docx

At the last meeting, members asked PSPN member Stephen to share the poster he had created to encourage patients and families to contact him. His initial draft poster (alongside a 'Freedom To Speak Up' poster) is attached below for anyone interested in doing something similar. 

@Stephen Heard 

Poster.pptx

Hi @Kellie Wilden, thank you for sharing your experience. The issues you raise regarding availability of medication and the associated challenges of changing brand are really interesting, and very frustrating for patients who need their medication. Thank you also for highlighting that this was via a private route too as it helps us to understand the wider picture and all of it's complexities. 

Have you been given any reason for the medication not being available or indication of when it would be? 

Thank you @Darren for sharing your knowledge.

Thank you @Darren for sharing yours and your daughters experience and insights. And for highlighting the wide ranging impact on people when they do not get their medication. Your perspective is of enormous value to this conversation. 

In your role as a pharmacist, do you get told the reasons for supply issues? Are there some common themes? Do you have any changes you would make to help the system run more smoothly and reduce supply issues?

Have you (or a loved one) ever been prescribed medication that you were then unable to get hold of at the pharmacy? 

• Was there an impact on your health (physical and mental)? 
• Were you told the reason for it not being available? 
• Was the issue resolved? If so, how long did it take?
• If you are still impacted by medication supply issues, have you been told when you will be able to access them again?

To help us understand how these issues impact the lives of patients and families, please share your experience and insights in the comments below. You'll need to register with the hub first, its free and easy to do. 

We would also like to hear from pharmacists working in community or hospital settings, and others who have insights to share on this issue. What barriers and challenges have you seen around medication availability? Is there anything that can be done to improve wider systems or processes?

Please comment below or email us at content@pslhub.org

Notes from the meeting on 9 January 2024.

The 5th meeting of the Patient Safety Partners (PSP) Network focused on engaging patients and families in patient safety. These discussions developed naturally to include conversations around:

•    The impact of PSIRF on engagement
•    Different engagement approaches across different healthcare organisation settings and areas
•    Cultural enablers and barriers to engagement
•    The PSP role and where it should sit within the engagement process
•    Duty of candour
•    Wider engagement with the public, Healthwatch, coroners etc.
•    Using the collective voice of the PSPs for change and influence
•    Supporting tools, resources and literature.

There was also an update on the next steps for the PSP survey and the plan to have new people chairing the meeting in the coming months.

Members have also been asked to contribute ideas for future meeting topics and/or presenters. You can share your ideas here.

Patient Safety Partners Network meeting notes 9 January 2024.docx

Hi @Sabrinapsychologist

Thank you for reaching out via the forum. Capturing lived experience will be an important part of understanding the issues and how improvements can be made. 

We will also add your information about the study to the main 'Learn' library so we can share your research request via our other channels.

In an opinion piece published on the hub today Luke* talks about Post-SSRI sexual dysfunction (PSSD).

Long-lasting sexual dysfunction after taking antidepressants: Lack of recognition harmful to patients

Luke argues that further action needs to be taken if we are to see long-lasting improvements in the care and treatment of patients with PSSD. He calls for:

• Widespread acknowledgement of the condition.
• Doctors provided with up-to-date information and training (informed by lived experience) on the dangers of antidepressants and how to support patients.
• Warnings on instructions for the medications updated and prescribing clinicians alerted to ensure patients are adequately informed.
• An awareness and media campaign launched targeting patients, prescribers and the public.
• Funding secured for research that helps us gain an understanding of the underlying pathophysiology, identification of a diagnostic biomarker and, eventually, a cure for PSSD.
• Doctors listening to patients so they can understand how PSSD is a life-changing condition and be able to refer to support services.

Have you had an experience relating to the article? What do you think should be done to improve patient safety? 

Please comment below (sign up first for free) or get in touch with us at content@pslhub.org to tell us more.