Previous seminars

MEDICATION SAFETY – PROBLEMS, SOLUTIONS AND CHALLENGES: Professor Bryony Dean-Franklin, 27th October 2017

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Abstract: The use of medication is one of the most common interventions in today’s healthcare. Medication use takes place in many different settings and involves many different health care professionals as well as patients and their carers – and errors can arise at any stage. This presentation will set the scene by describing some of the problems that can occur, before considering some solutions and challenges, drawing on evidence in this field. Potential solutions include the use of technology (both high tech and low tech), human factors, system design, communication strategies and greater patient involvement. Suitable solutions must also take into account both a ‘medical’ view of safety (the avoidance of harm) and a ‘patient’ view of safety (‘feeling safe’). Challenges include the importance of context (what works in what setting may not work in another), fidelity of implementation, unintended consequences, and the ubiquitous nature of medication use and wide range of stakeholders involved.

Biography: Professor Bryony Dean Franklin is Director of the Centre for Medication Safety and Service Quality (CMSSQ), a joint research unit between Imperial College Healthcare NHS Trust and UCL School of Pharmacy, where Bryony is Professor of Medication Safety. She is a theme lead for both the NIHR Imperial Patient Safety Translational Research Centre and the NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London.

Bryony has been involved with patient safety research for nearly twenty years, and has published widely on medication safety, the evaluation of various technologies designed to reduce errors, and how we can support the public role in patient safety. Her current post combines research, education and training, and clinical practice as a hospital pharmacist. Bryony is an associate editor for the journal BMJ Quality and Safety, and on the editorial board for BMC Safety in Health. She is co-editor of the textbook “Safety in Medication Use” and co-author of “Going into Hospital? A guide for patients, carers and families”, a book aimed at the general public.

Presentation slides available here

PATIENT SAFETY: THE END OF THE BEGINNING OR THE BEGINNING OF THE END? Professor Jeffrey Braithwaite, 12th October 2017

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Abstract: I last spoke to the Bradford Institute for Health Research on the topic of Resilient health care: re-conceptualising patient safety. Two years on, and along with members of the Resilient Health Care Network, we have published another book (Braithwaite, Wears and Hollnagel, 2017, Reconciling Word-As-Imagined and Work-As-Done), with three more volumes in various stages of production. Leveraging from this work, I will analyse recent developments in patient safety and discuss a number of issues crucial to understanding where we are in the perennial search for better ways to care for patients in safe, effective environments.

I will draw not only on the compendiums making up the contributions of the Resilient Health Care Net, but also on two other recent contributions of note. One is The Sociology of Healthcare Safety and Quality (Allen, Braithwaite, Sandall, Waring, (eds.), 2016). The other is recent work on applying complexity science to health care (Braithwaite, Churruca, Ellis, Long, Clay-Williams, Damen, Herkes, Pomare, Ludlow, 2017, Complexity Science in Healthcare—Aspirations, Approaches, Applications and Accomplishments: A White Paper).

The bottom line is that despite the doomsayers saying that it is proving very hard to make progress in patient safety as it is such an intractable wicked problem, it’s better to say that we are at the end of the beginning of the patient safety movement rather than at the beginning of the end. But, in the end, that will be up to each individual in the audience. There will be time for discussion at the conclusion of this presentation.

Biography: Professor Jeffrey Braithwaite, BA, MIR (Hons), MBA, DipLR, PhD, FAIM, FCHSM, FFPHRCP (UK), FAcSS (UK), Hon FRACMA, is Foundation Director, Australian Institute of Health Innovation, Director, Centre for Healthcare Resilience and Implementation Science, and Professor of Health Systems Research, Macquarie University, Australia. His research examines patient safety, health care as a complex adaptive system, and applying complexity science to health care problems. He has attracted funding of more than AUD$102 million and has received 37 different national and international awards for his teaching and research.

REDUCING EMERGENCY ADMISSIONS: Dr Suzanne Mason, 6th July 2017

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Abstract: Emergency and urgent care provide substantial health benefit across the world but increasing demand is leading to unsustainable pressure on services and a need for innovative approaches to the delivery of emergency and urgent healthcare for patients. In the English NHS in 2012-13 there were 18.3 million attendances at major emergency departments, single specialty emergency departments, walk-in centres and minor injury units, at a cost of £2.1 billion; 5.3 million emergency hospital admissions, at a cost of £12.5 billion; 7 million ambulance service journeys; and approximately 24 million calls to NHS emergency and urgent care telephone services.

Failure of the emergency and urgent care system to manage increasing demand causes substantial public concern and political impact. Delays in ambulance response or emergency department assessment can lead to worse outcomes for patients. Emergency department crowding is internationally recognised and may be associated with avoidable mortality. These issues make the delivery of emergency and urgent care an important priority for policy-makers, service providers and the public. The emergency and urgent care system inextricably links services together that rely on each other, and also that work together to deliver care for patients. This study is using data from the Yorkshire Ambulance Service and NHS 111 and linking it with hospital data (ED/Inpatient) from every acute trust in Yorkshire and Humber to analyse patient demand, flow and outcomes through these parts of the system.  In addition to an overall view, we have focussed on patient groups who may benefit from a different approach to their emergency care. This includes vulnerable patient groups such as those who have mental health problems, the elderly, patients who attend frequently and also patients with primary care-related problems. The presentation will provide an overview of the project and describe some of the analyses and outputs to date.

Biography: Suzanne qualified in medicine from London University in 1990. She pursued her training initially in surgery and then specialised in Emergency Medicine. Suzanne spent a year as a Royal College of Surgeons of England Research Fellow and was awarded an MD whilst undertaking higher training in Emergency Medicine. She joined Sheffield University as a Senior Clinical Lecturer in 2001 and was promoted to Reader in 2007 and Personal Chair in 2010. She divides her time between the university and as a consultant at the Sheffield Teaching Hospitals Trust emergency department. Her main research interests include evaluating complex interventions in emergency and urgent care. She is particularly interested in the evaluation of new roles and alternative pathways of care.

Recent studies include evaluating junior doctor confidence and competence in carrying out their role in emergency medicine (The EDiT study), evaluating the use of a falls pathway by paramedics attending older people who have fallen (SAFER 2 Trial), and The AHEAD Study: Managing anticoagulated patients who suffer head injury, Using routine data to evaluate the Emergency and Urgent care System (http://clahrc-yh.nihr.ac.uk/our-themes/avoiding-attendance-and-admissions-in-long-term-conditions).

IMPROVING PATIENT SAFETY THROUGH LEARNING FROM COMPLAINTS: Dr Tom Reader, 22nd June 2017

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Abstract: Healthcare organisations receive large volumes of complaints; for example in 2015-16 the NHS received over 100,000 complaints from service users (patients and their families). Traditionally complaints have been seen as something to manage or even hide.  However, listening to service user complaints can potentially provide independent, practical, and unique insights for improving patient safety and quality. This lecture reports evidence using the Healthcare Complaints Analysis Tool, which is the first reliable tool for systematically analyzing and benchmarking the nature and severity of complaints received by hospitals. It shows that complaints from patients and families highlight systemic problems in the provision of safe and high-quality healthcare, and are associated with hospital-level mortality rates. This evidence supports the idea that complaints have high validity and can be used both as an early warning system for identifying systemic failures in healthcare organisations, and as a catalyst for organizational learning.

Biography: Tom Reader is an Associate Professor in the Department of Psychological and Behavioural Science at the London School of Economics and Political Science. His research examines the relationship between organisational culture and safety management in high-risk organisations, and has been conducted in a variety of settings (healthcare, aviation, energy, finance). Dr Reader’s research has been disseminated through outlets such as Risk Analysis, BMJ: Quality and Safety, Journal of Occupational and Organizational Psychology, Human Factors, Ergonomics, and Human Relations.

SAFETY HUDDLES: Dr. Ali Cracknell and Alison Lovatt, 20th April 2017

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Abstract: Patient harms are estimated to cost the NHS more than £2.3billion per year.  For example, inpatient falls can lead to hip fractures and other injuries, whilst even falls without harm can lead to loss of confidence and increased length of stay for patients.

Team huddles have been used for many years and across many industries to improve team-working and communication but in Yorkshire, the Improvement Academy has combined the notion of a team huddle with improving patient safety and team working. We have worked with over 150 frontline teams since 2013 to implement our Huddle Up for Safer Healthcare (HUSH) programme.

In this talk we share some of our learning about what makes a Yorkshire Huddle effective and sustainable. We will also share some early findings from the evaluation currently being undertaken by the University of Bradford.

Biography: Ali is a Consultant in Medicine for Older People. She has a passion for patient safety and improvement, in particular implementing innovations in patient safety into frontline clinical practice. She has worked on many successful frontline QI projects including reducing harm from misplaced nasogastric feeding tubes, reducing falls and reducing cardiac arrests.  Ali is leading the programme of work to scale up patient safety huddles on hospital wards within three NHS trusts.

Alison has worked in the NHS for over 30 years. She is a trained Nurse and Midwife. Alison has worked to address patient safety issues for the last 7 years. She is the Improvement Academy’s Clinical Network Director and concentrates on working with frontline teams and implementing safety huddles as a means to improve patient safety culture and reduce harm. Alison also supports the Improvement Academy’s 150 Improvement Fellows.

Presentation slides available here