Learning and Change for Patient Safety

Implementing Patient Safety Alerts (NPSA)

The Team: Beverley Slater, Natalie Taylor, Victoria Robins

Patient safety alerts are issued by the National Patient Safety Agency (NPSA) to the National Health Service, in response to analysis of reported patient safety incidents and other safety knowledge.  Compliance is mandatory, and is self-reported by each organisation. However, implementation is rarely straightforward.  The steering group of the HIEC patient safety theme has supported work to prioritise implementation of patient safety alerts and to improve implementation of certain NPSA patient safety alerts by: diagnosing barriers to implementation, designing an implementation package to address those barriers, evaluating effectiveness.

For further information please contact Beverley.Slater@yhahsn.nhs.uk


Training & Action for Patient Safety

Training and Action for Patient Safety is a training programme helping multi-professional clinical teams to develop innovative solutions to address common patient safety problems such as: Handover, Medicines safety, Suicide prevention, VTE assessment and management, Patient transfer, Falls.

The programme runs over 20 weeks and involves attendance at an orientation meeting and three learning workshops (one full day and two half days). The programme is attended by up to 10 teams from different organisations across the local healthcare economy. Teams undertake a training module in patient safety, and then are supported to identify a local priority for patient safety, develop solutions and measure improvement.  The TAPS programme was designed by Bradford Institute for Health Research and the Improvement Foundation in collaboration with a panel of active clinicians who are experts in patient safety.

TAPS programmes have already taken place in Bradford, North Lincolnshire, Doncaster and Sheffield.  Current TAPS programmes are active in Leeds and York. Further TAPS courses will be taking place across Yorkshire and the Humber region in 2011/12.

For further information or to express an interest please contact: Beverley.Slater@yhahsn.nhs.uk 


Situational Awareness Vital Insights (SAVI)

The Team: Rebecca Lawton, Angela Grange, Gerry Armitage, Jane Saunders, Claire Coulson, Liz Thorp

Acknowledgements to: Andrea Lealman, Angela Grange, Caroline Butterfield, Caroline Reynolds, Cheryl Cockayne, Claire Coulson, Dr Donald Whitelaw, Dr Harry Ashurst, Dr John Bibby, Dr Mark Purvis, Gill Atherton, Hoshiar Singh, Ikhlaq Din, Jane Saunders, Liz Thorp, Pauline Brown, Professor Ian Watt, Rachel Lawton, Richard Brown, Ruby Bhatti, Sandra Dudding and Shoba Srinivasan.

With Thanks to: MezzoFilms

Situational awareness (or a lack of) has been identified as an important factor contributing to human error.  This interactive tool is being designed as a web-based system (or stand-alone DVD) for use in the induction of new staff to help enhance their situational awareness as they begin practice in healthcare. There are four scenarios of high risk situations in which errors are common, these are: prescribing and administration of insulin; handover/team briefing; deteriorating patient; diagnosis

Register your interest in using the situational awareness tool in your organisation by contacting us Beverley.Slater@yhahsn.nhs.uk