2.1 Safety in healthcare

Safety in healthcare refers to the reduction of risks and the minimisation of harm to patients.

The following video outlines how a team working in hospital surgery responded to greater numbers of Never Events. A Never event is a preventable or avoidable event that did, or could have, caused a patient serious harm or death. For example, the current list of Never Events in the NHS (England and Wales) includes conducting surgery on the wrong part of the patient (wrong site surgery) and leaving instruments in the patient after surgery (retained instrument post operation; NHS England, n.d.b).

Activity 3

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Transcript: Improving patient safety

[MUSIC PLAYING]

Iain Moppett:

So Change programme has been looking at improving the safety of patients in theatres. We had a run of a lot of never events a few years ago. And that really focused our mind on how to improve the care that we’re providing our patients.

Maria Shallow:

We basically asked the teams to see what ideas that they thought and that they could come up with and, obviously, also listened to staff on the ground floor. We also put in a patient safety lead. We’ve had different leads going through the last few years with our ideas.

Iain Moppett:

Well, a good example of that is the emergency laparoscopy project which we’ve been doing, where the idea of how to improve was taken from an evidence base but was very much driven by medical staff and by theatre staff saying, well, look, we know what the problems are with the way these patients come through theatres. We know that they get delayed. They’re not getting the scans as quickly as they might do. Let’s look at how we can make that better.

And they really got together, developed that, been supported by management. But they’ve very much driven that from the ground up. They’ve seen the problems, and they’ve tried to resolve those.

Yuliya Johnson:

Patient safety champions, they’ve been introduced in a Nottingham hospital for a few years now.

Maria Shallow:

We have 47 operating theatres. And each theatre has a champion assigned in that theatre that works for the team and is able to champion the safety agenda within each theatre, so looking at the safety WHO checklist, looking at the quality of what we’re doing in terms of the briefings and debriefings.

Alison Adkin:

My role is to oversee the patient safety champions, listen to what is happening on the ground floor within theatres. So I have the time to facilitate training, encourage staff to engage with the five steps, also organise the champions, and feed up to the governance programme within theatres.

Yuliya Johnson:

I think patient safety champion role makes it easier for governance team and for patient safety leads to communicate with every theatre and to cascade the messages of safety down to every member of the team.

Alison Adkin:

The introduction of the patient safety lead role has impacted not only the five steps but the engagement with the WHO checklist while the patient is in the anaesthetic room. And I think for patients, that gives them the assurance that everything is checked. And their operation is absolutely confirmed.

Iain Moppett:

The most innovative feature, I think, actually, is putting it all together. It’s not that any one thing is a magic bullet, which is sorting something out - but I think what we’ve done is said, actually, we’re going to do, it’s all of these bits together. We’re going to listen to our staff. We’re going to find out what the problems are. We’re going to focus on getting the mandatory training right. And we’re going to try to learn from our incidents.

Yuliya Johnson:

Currently, with the patient safety champions, we manage to access our incidents database quite quickly. We can share learning from our incidents between the floor staff.

Iain Moppett:

In terms of impact, I think there’s different ways to measure that. Clearly, we started off looking at never events in surgery. And those have dramatically reduced. And that’s a clear evidence of impact.

Yuliya Johnson:

People found their voices, and people found the places where they can voice their opinions about patient safety. And there are so many levels that it could be utilised there.

Maria Shallow:

Without the empowerments, I don’t feel that you get effective change. So as leaders, we can say about a change that we’d like to happen. But actually, the ground floor staff are the ones that are actually going to be able to embrace that change and go along with the change that you’re wanting to make. And everybody feels, that actually, in our theatre teams, that we deliver a high quality-led service. And that we do the best for our patients.

[MUSIC PLAYING]

End transcript: Improving patient safety

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Improving patient safety

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1. What are the key messages from this video?

2. Thinking about what you have learnt from this video, can you think of any ways to monitor the safety of healthcare?

Discussion

1. The video highlights the importance of patient safety ‘champions’ or ‘leads’. The practitioners featured emphasise the importance of listening to staff and empowering practitioners, of sharing learning in the team, and of collaboration between different professionals.

2. Investigating any instances of Never Events occurring in a hospital could give one indication of the safety of the healthcare.

The interactive guide ‘In Safe Hands’ [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] , produced by Health Education England (HEE), offers guidance and examples of how healthcare workers can adopt safe clinical practice and improve the safety of patients in the care sector.