Patient Safety Learning Newsletter - December 2017

Thank you for taking the time to sign up to the Patient Safety Learning newsletter and welcome to our very first edition!

  • 8th January 2018
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Thank you for taking the time to sign up to the Patient Safety Learning newsletter and welcome to
our very first edition!

As you will know by now, we launched in September 2017 at The King's Fund in London. If you
attended our launch, thank you so much for coming and helping to make the event such a
memorable occasion. We have produced a short film of the launch – please have a look here.

A bit more about us
Patient Safety Learning has been founded by Jonathan Hazan and James Titcombe. We are not for
profit, with our initial funding generously provided by Datix. Our mission is to help healthcare
organisations around the world protect patients from avoidable harm by sharing learning, promoting
best practice and encouraging a culture of safety for patients and healthcare workers.
We are lucky to be supported by a fantastic steering group who you can read more about here.

Our work to date
It’s still early days for Patient Safety Learning and some of our big areas of future work are still under
development, but we have already launched some exciting initiatives.

In September, we published a series of three podcasts produced in partnership with Professor
Murray Anderson-Wallace. These explore the complex issues surrounding how healthcare
organisations respond to avoidable harm. We’ve had some great feedback from healthcare
professionals and patients who have listened to these and we hope they will provide a useful
resource to help frame conversations about how to make positive changes.

These podcasts are available with free access from our website, so please have a listen and if you
find them useful, please help spread the word.

Changing perceptions around incident reporting and learning from mistakes
We believe that learning from things that go wrong in order to improve patient safety should be
encouraged and celebrated but we know that the culture in healthcare doesn’t always support this.
This is one of the reasons why we have recently launched an awards scheme specifically focused on
patient safety improvement, culture and working with patients and families to make healthcare

The scheme is open to all healthcare organisations in the UK (we may expand this to other countries
in the future). There are two awards in each of the following categories:

1. Patient safety improvement projects linked to reporting systems and investigation of patient
safety incidents, events, near misses and examples of good practice.

2. Engaging patients and their families in safety improvement initiatives. This is a joint award in
partnership with Action Against Medical Accidents (AvMA).

3. Improving the environment in which staff are able to raise and address safety concerns.

Full details of the awards scheme, judging criteria and how to enter are available on our website

All submitted nominations will be judged by independent experts and winners and runners up in
each category will be announced in September 2018.

There are 6 cash prizes which can be used by the winning organisation for any patient safety project
or initiative, so please consider submitting a nomination and help spread the word!

Our future work

We are currently working on a project with Dr Carl Macrae to develop a new platform to help share
patient safety learning, not just in the UK but with healthcare organisations around the world. We
will be announcing more details about this work early in 2018.

We are also developing a range of training options for healthcare providers, in areas such as duty of
candour, engaging patients and families following healthcare harm, investigating adverse events and
implementing strategies to improve patient safety. We will be working in partnership with Action
Against Medical Accidents (AvMA) and Consequence UK and will be announcing more details in early

Patient safety in the news
It seems like hardly a week goes by when a major story relating to Patient Safety isn’t in the news. In
this newsletter, we wanted to share some of recent developments in maternity safety.

New maternity safety announcements
Improving the safety of maternity services has been high on the national agenda since the
publication of the Morecambe Bay investigation report in March 2015. In November 2017, the
government announced a series of new measures aimed at addressing some known problems and
improving maternity safety in the NHS. You can read about the full range of measures here.

Of real significance, from April 2018, the Healthcare Safety Investigations Branch (HSIB) will
undertake independent investigations into stillbirths and neonatal deaths that meet the inclusion
criteria for the Each Baby Counts project. There have been a number of recent reports that have
highlighted that many adverse outcomes in maternity services in England are avoidable and that
currently systems of investigation and learning simply aren’t good enough. James has shared his
reaction to the proposals in this article in Guardian.

The measures could be a real step change for maternity services, helping to ensure that when care
does go wrong, high quality inquiry and learning takes place. Hopefully, these changes will go hand
in hand with efforts to build capacity and expertise in patient safety investigations and learning
across the system.

Introducing Alison Leary
We are incredibly lucky to be supported by our steering group of people with huge experience and
passion for patient safety. As part of our regular newsletter, we thought we would introduce a
member of our steering group and share their reflections on how they became involved in patient
safety and what key priorities for change lie ahead. In this edition, we’re pleased to introduce Professor Alison Leary.

After spending ten years in science & engineering, Alison qualified as a nurse in 1996 at St Thomas
Hospital & King’s College London. Prof. Leary obtained a PhD in clinical medicine from the University
of London (Royal Free & University College School of Medicine) and her academic background
encompasses science, nursing, medicine and mathematics.

Prof Leary’s work looks at the modelling of complex systems, including the workforce. She has just
completed a Winston Churchill Memorial Trust Fellowship looking at the use of data in high
reliability organisations.

We asked Alison to share a bit more about how she became involved in patient safety and what she
sees as key priorities for change in the future. Alison writes:

I have worked in or around healthcare for most of my adult life. I'm sorry to say for most of it I never
really thought about safety. If I had time to reflect at all, it was about getting the seemingly never
ending work done. I don't recall anyone ever mentioning safety, it certainly wasn't taught in any of
the nursing or medical school courses I attended. In fact the only education I had in safety was in my
previous life in engineering or as part of being the lead for the crowd medical service in an English
football league club.

In healthcare my colleagues and managers never mentioned safety either. Looking back I find that
faintly ironic. I spent over half that time as a registered nurse whose primary function is keeping
people safe. We did it every day, to the best of our ability, but we never talked about it. When I talk
to nurses now, they don't always see that either but in reality the nursing and care workforce are our
best assets in safety-they are by far, the largest part of the workforce. I am passionate about helping
release that potential.

My background is in physical sciences and I’ve always enjoyed maths. I'm really interested in turning
the masses of data collected every day in healthcare into useful knowledge that can improve care,
make it safer and even save lives. Added to my own experiences of working in different services and
in recent years as an expert witness, I think this untapped data is a great opportunity.

One of the key challenges is the type and quality of the data (for data to be useful it has to reflect
our real world) and another is thinking about the effort that goes into collecting it. Routine data
collection takes up a large part of front-line staff time, only to be stored and not used, or used when
its poor quality data to inform decision making, sometimes with catastrophic consequences.
Another key challenge is the gap between what Erik Hollnagel calls work imagined and work done.
There is a massive gap in knowledge about the work of healthcare between those who deliver it and
strategic decision makers. Often this manifests itself when decision makers explain how health work
is time filled with tasks (it isn’t) but I think we can build an infrastructure to bridge that gap. This gap
in knowledge means the way we utilise our workforce in healthcare is also very different to safety
critical industries. Health & social care tend to have a "service" model like hospitality or retail, rather
than safety critical model such as the oil or aeronautics industry. This means we have a far more
inexperienced workforce on the front line and policy encourages this expertise to become diluted to
provide the volume of care required at lower cost. I was fortunate enough to spend 2016 with a
number of safety critical high reliability organisations that have a safety infrastructure that was
independent of the management hierarchy, encompassing policy, legislation, data and culture.
I’d like to see high quality data used to make healthcare safer, retention of front-line expertise and
the introduction of a safety infrastructure that runs alongside managerial hierarchy into healthcare
in the UK. Some organisations work really hard at this but it’s a struggle for others. I’m hoping that
together we can make healthcare safer for everyone.

You can read more about my Winston Churchill Memorial Trust Fellowship to NASA, CERN and other
HROs here:

Hope is not a plan: Can healthcare in the UK learn from other safety critical industries? | WinstonChurchill Memorial Trust

And finally…

On behalf of the Patient Safety Learning team, thank you again for your interest our work. It’s still
early days for us at the moment and in our next newsletter we hope to share much more detail
about some of our long term project work and how you can get involved.

If you have any questions, comments or suggestions, we’d love to hear from you and you can get in
touch via the contact us section of our website.

In the meantime, thank you all for your interest in Patient Safety Learning and wishing you all a
merry Christmas and a happy New Year.

Best wishes
The Patient Safety Learning Team


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