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Content Article
The Patient Safety Management Network (PSMN) started on a Friday afternoon in June 2021 as three people in a Zoom meeting. In this interview, PSMN founder Claire Cox reflects on why the network has grown to have over 1600 members and what it has achieved over the past three years. She outlines how the network has fostered a safe space for staff to raise issues and shares feedback from members about what they love about the PSMN.- Posted
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Content Article
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In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, explains how she became involved in Appreciative Inquiry and asks the question: what could Appreciative Governance start to look like in the NHS and what small steps can we all do to achieve that together? -
Content ArticleCaring Corner is a podcast hosted by Katy Fisher and Kayleigh Barnett sharing real stories of Appreciative inquiry in health and care.
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EventuntilSince the publication of the PSIRF learning response toolkit in Aug 2022 healthcare providers across the NHS in England have been exploring the application of different tools made available for learning and improving following a patient safety event. After Action Review (AAR) is one such tool. In response to feedback from providers, NHS England, HSSIB and AAR experts have produced a draft AAR report template to use to summarise the output of an AAR. This webinar will explain the template design and include some reflections from a provider that has tested the template in practice. The draft template is available on FutureNHS here: AAR Resources - NHS Patient Safety - FutureNHS Collaboration Platform Recordings, slides and Q&As will be made available on Future NHS here: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, NHS England Melanie Ottewill, HSSIB Judy Walker, AAR expert Jane Carthey, Human Factors and Patient Safety expert Gabby Walters, Royal London and Mile End Hospitals Register
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Magda talks to us about her role as Family Liaison Officer Team Lead, how PSIRF has changed the way her Trust involves patients and families after patient safety incidents and the importance of placing patient and family perspectives at the heart of learning responses. -
News Article
‘Burdensome’ patient safety inquiries taking up too much time, says NHSE chief
Patient Safety Learning posted a news article in News
NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content ArticleThis template standardises the reporting of After Action Reviews (AARs). It is not intended to be an AAR facilitation guide. The template has been co-designed with staff leading AARs in a range of healthcare organisations. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed by the National Patient Safety Team. It can be downloaded from the attachment below or it's available on FutureNHS within the AAR tool space here: https://future.nhs.uk/NHSps/view?objectId=42826256
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EventJoin Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in collaboration with Radar Healthcare for an engaging discussion on Learning from Patient Safety Events (LFPSE) and the Patient Safety Incident Response Framework (PSIRF), highlighting their combined impact on patient safety improvement. This webinar will delve into pivotal aspects crucial for integrating LFPSE and PSIRF into your incident and reporting software, including: User-Centric Approach: Understand the significance of aligning LFPSE and PSIRF principles with the end-user's perspective, ensuring a seamless and intuitive experience. Success Story: Learn how GSTT implemented both LFPSE and PSIRF, surpassing standard levels of incident reporting and advancing patient safety practices. Data Empowerment: Discover how GSTT was able to address its patient safety priorities and facilitate the provision of critical data to the national patient safety improvement programs led by NHSE. This session will spotlight how GSTT adapted to new processes and frameworks like LFPSE and PSIRF, contributing to both national and local safety initiatives. Speakers: Charles Martin, Trust Head of Risk and Quality Assurance - Guy’s and St Thomas’ NHS FT Paul Johnson, CEO - Radar Healthcare Jack Forshaw, Project & LFPSE Lead - Radar Healthcare Chair: Jon Hoeksma, CEO - Digital Health Register
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EventThis training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. WHO SHOULD ATTEND Executives, commissioning, & service managers supporting service lead investigator roles. The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventTraining to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Event
Duty of Candour
Patient Safety Learning posted an event in Community Calendar
This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. WHO SHOULD ATTEND Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. KEY LEARNING OBJECTIVES Understanding the importance of communication in a clinical context and the role of the duties of candour. Appreciating the difference between the statutory and professional duties of candour. The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent. Understanding the process when the duty of candour is triggered. Understanding the relationship between the duty of candour and fault / blame / liability. The legal implications of an apology and what makes a good apology. Register hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Mark talks to us about his role as a National Patient Safety Partner (PSP). He explains the important role that PSPs play at national, regional and local levels of the healthcare system and identifies key opportunities and challenges they face in bringing the voice of patients and families at a strategic level. He also highlights the challenge of implementing the Patient Safety Incident Response Framework (PSIRF) across a diverse range of providers and the complexities arising where PSIRF interfaces with systems and processes outside of the NHS. -
Event
After Action Review Masterclass
Sam posted an event in Community Calendar
An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code. -
Event
NHS Complaints Summit
Sam posted an event in Community Calendar
This National Virtual Summit focuses on the New PHSO National NHS Complaint Standards which are now being used and embedded into the NHS. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect how involving people and their families in complaints and integrating the process with the new Patient Safety Incident Response Framework (PSIRF) to ensure patient safety actions and learning. https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email frida@hc-uk.org.uk for further information. Follow the conference on Twitter @HCUK_Clare #NHSComplaints hub members receive a 20% discount. Email info@pslhub.org for the discount code. -
Content Article
Appreciative inquiry case study
katy.fisher posted an article in Patient Safety Incident Response Framework (PSIRF)
Appreciative inquiry is one of the Patient Safety Incident Response Framework (PSIRF) tools that can be used to learn from patient safety incidents. Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares how she designed and introduced an appreciative inquiry tool at her hospital.- Posted
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Content ArticleJudy Walker describes how an After Action Review following a sporting event ensured significant learning took place and led to a worldwide change in first aid training.
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Content ArticleEnsuring the safe and effective use of medicines is a central function of the pharmacy team. This article in the Pharmaceutical Journal outlines how pharmacists can support the implementation of the Patient Safety Incident Response Framework (PSIRF). It aims to help pharmacists: understand the role of the Patient Safety Incident Response Framework (PSIRF). understand the difference between the PSIRF and the Serious Incident Framework. Know how the PSIRF can be applied to the pharmacy profession. This content is free to access but you will need to sign up for a Pharmaceutical Journal free online account.
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Content ArticleCentral to the Patient Safety Incident Response Framework (PSIRF) is the requirement for healthcare organisations to be proactive in how they respond to and learn from patient safety incidents. This article from legal firm Kennedys considers the implications of PSIRF on healthcare organisations’ legal and governance teams. In particular, considering practical steps that may be adopted, as an example, in the context of preparing for an inquest.
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Content ArticleThis leaflet produced by East London NHS Foundation Trust (ELFT) explains the Patient Safety Incident Response Framework (PSIRF) to patients and families, outlining the aims of PSIRF and what they can expect from the process.
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Content Article
Chris Elston, a patient safety education lead, shares how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from a patient safety incident at his Trust. -
Event
The Patient Safety Incident Response Framework & Clinical Audit
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register -
Event
The Patient Safety Incident Response Framework & clinical audit
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register -
EventThis one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register
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Systems approach to learning from patient safety incidents
Sam posted an event in Community Calendar
untilTraining to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Register -
Event
Systems approach to learning from patient safety incidents
Sam posted an event in Community Calendar
untilTraining to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Register
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