Abstract: Improving patient safety in healthcare settings is a major concern globally. Medicines are the most commonly used clinical intervention in healthcare, and errors involving the prescribing, dispensing, administration and monitoring steps of medication use are common. Such medication errors can prolong hospital stay and lead to significant patient morbidity. Given this, the World Health Organisation has recently identified ‘Medication Without Harm’ as the priority for their third Global Patient Safety Challenge which aims to reduce severe avoidable medication-related harm by 50% globally in the next 5 years.  In primary care settings, we have been working to address these challenges focused on reducing hazardous prescribing as part of the work programme within the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC). The seminar will focus on the interventional studies underway, lessons learnt and plans for the future.

Biography: Darren holds the Foundation Professorship in Pharmacoepidemiology and is Head of the Drug Usage and Pharmacy Practice Group at the University of Manchester. He is the Deputy Director of the NIHR Greater Manchester PSTRC, in which he also leads the medication safety research theme. He is also a member of the Pharmacovigilance Expert Advisory Group (PEAG) at the Medicines and Healthcare products Regulatory Agency (MHRA).

As a pharmacist and pharmaco-epidemiologist, his major research interests and teaching include: methods to improve the appropriateness and safety of drug prescribing and drug taking, and quantification of the risks and benefits of drug therapies. He has led extensive research programmes focused on patient safety in a wide range of healthcare settings (hospitals, general practices, and pharmacies), with particular expertise in understanding and improving medication safety.

Presentation slides available here

Abstract: Quality and safety of care remains a priority for the NHS but approximately 5% of deaths in English hospitals are preventable, and attributed to poor quality of care.  Patients who are admitted to hospital towards the end of their lives can experience inadequate decision making, poor communication and suboptimal treatment and there is the need for clinical staff to recognise as soon as possible that a person is dying and to communicate this clearly to others.  Over a two year research study in two NHS hospitals, a suite of four automated risk scores was developed that use routinely collected electronically stored data to provide clinicians with estimates of patients’ risk of death and sepsis during their stay in hospital. These scores rely on two key clinical data sources – the patients vital signs data as defined and monitored by the National Early Warning Score (NEWS) and routine blood test results.  Staff and patient involvement has been integral to the development of the scores.  In this presentation, we outline the findings of 8 focus groups involving 11 service users and carers, and 45 health care practitioners, and explain how these have contributed to an understanding of value and potential use of the scores in practice.

Biography: Dr Judith Dyson is a registered general and mental health nurse, a health psychologist and her research focuses on the use of psychological theory in supporting practitioners in implementing best practice.

Dr Claire Marsh is a research fellow in quality, safety and patient experience and also leads patient and public engagement for the Yorkshire & Humber Improvement Academy.

Presentation slides available here

Abstract: Nursing and healthcare in the 21st century is charged with delivering high quality care within an increasingly diverse society. Much of the policy, practice and research drivers around cultural competence, diversity and nursing practice focuses on meeting the needs of patients, service users and the public – particularly following the findings of the Francis Report (2013). However, recent reports have highlighted that highlighting the need for compassionate care for patients often occurs in isolation from recognising the needs of the workforce or the nursing profession as a whole – in this regard we do ourselves a dis-service – and in the silent spaces between patient need and workforce responsibilities, we fail to acknowledge the importance of professional leadership as the catalyst to delivering the high quality, equitable and culturally competent care that we all hope for. This presentation will use personal and professional reflections to highlight the importance of culturally competent and compassionate leadership to truly achieving safety and quality in 21st century health care. It explores the challenges and opportunities faced at an individual and professional level in the UK. It looks back at nursing strategic drivers of the last 3 years in the UK and makes a case for centralising culturally competent, compassionate leadership in the light of the new strategic framework for nurses, midwives and care staff (2016)

Biography: Professor Laura Serrant OBE is Professor of Nursing in the Faculty of Health and Wellbeing at Sheffield Hallam University, one of the few black Professors of Nursing (out of 262) in the UK. She is one of the 2017 BBC Expert women, Chair of the Chief Nursing Officer for England’s BME Strategic Advisory group and a 2017 Florence Nightingale Scholar. She is an ambassador of the Mary Seacole Memorial Statue and the Equality Challenge Unit Race Equality Charter for Higher Education. Her work has been recognised with numerous awards and prizes, including Queens Nurse status and Fellowship of the Queens Nursing Institute to those who have shown leadership in community nursing. In 2014, she was named as one of the top 50 leaders in the UK by The Health Services Journal in three separate categories: Inspirational Women in Healthcare, BME Pioneers and Clinical Leader awards. The Powerlist 2018 lists her as the 8th most influential Black person in the UK. She was awarded an OBE in the Queen’s Birthday Honours list this year for services to Health Policy.

Presentation slides available here

Abstract: Never Events are patient safety incidents that can cause harm or death and are so named because policy makers argue there is enough evidence available about how to prevent them, so they should never occur. Never events include wrong site surgery, wrong route drug administration, retained foreign objects and wrong implants. Between April-November 2017 332 Never Events occurred in hospitals in England, indicating that solutions to prevent them are not working. Although Resilient Healthcare is often described as a paradigm shift in safety management it is not clear how it can contribute to the investigation of adverse incidents. Root Cause Analysis (RCA) is currently used for the investigation of Never Events, but recent studies have found the recommendations to be of low quality. There is little incentive, time or resources for healthcare organisations to consider other approaches and little work has been done on how to use Resilient Healthcare insights to augment Safety I practices such as Root Cause Analysis. In this presentation the results of an analysis of 39 Never Events that occurred at one hospital over a two-year period will be discussed. The focus will be on the new insights and perspectives that Resilient Healthcare can offer to improve learning from Never Events. Recommendations for strengthening RCA and learning from Never Events will be discussed.

Biography: Janet Anderson is Director of the Centre for Applied Resilience in Healthcare and a Reader of Healthcare Improvement at King’s College London. She is a human factors psychologist. Her research draws on psychological and organisational theories and knowledge and is focused on designing systems to support safe human activity. She has specialist expertise in the theory and practice of organisational resilience, system modelling using cognitive work analysis, incident reporting and adverse event analysis, and inter professional teamwork. Board level processes and hospital wide systems for improving quality are an area of current research.

Presentation slides available here

Abstract: Inquiries, academic work and expert group reports on problems in the quality of care in the NHS and other healthcare systems have identified shortcomings in ‘openness’—that is, the extent to which organisations enable concerns to be raised and disclosed freely without fear—as critical to the incubation of failings in quality and safety. In response, the NHS in England has developed policy initiatives that seek to improve openness, including a statutory duty of candour when care processes give rise to harm, the introduction of ‘Freedom to Speak Up Guardians’ to facilitate staff voice about concerns, and changes to various processes, including the way serious incidents are investigated. The evidence base for many of these changes, however, is uncertain, and their impact on the quality of care unevaluated.

This paper discusses emergent findings from an ongoing evaluation of various openness initiatives in the NHS, focusing in particular on an interview-based sub-study of senior stakeholder views on the implementation and impact of these initiatives. It highlights some of the challenges involved in achieving greater openness given past experiences and deep-rooted beliefs about the (at best ambivalent, and often negative) consequences of being open, the difficulties involved in diagnosing opacity and fostering openness, and the approaches taken by senior clinicians and managers to translating policy into practice. It relates findings to current policy and wider evidence and theory on interventions to facilitate employee voice and achieve culture change.

Biography: Graham Martin is Director of Research for THIS Institute, a new unit funded by the Health Foundation at the University of Cambridge to develop the evidence base for and impact of work to improve healthcare quality and safety, and Professor of Health Organisation and Policy in the SAPPHIRE Group, University of Leicester. His research focuses on social, organisational and professional issues in healthcare system change, with a particular focus on quality improvement work and policy initiatives to address quality, safety and risk in the NHS.