It was great to have @katherinejoel join us at Winter Basecamp on the 20th January – thank you so much for coming! Katherine works for the Health Innovation Network South London and looks after the patient safety Communities of Practice springing up. We would love to see some collaboration and sharing across our two CoP Networks – some are covering similar if not the same topics. Please do get in touch with Katherine or me to make links with the CoP you’d like to know more about by messaging us through the website or email me directly. Exciting!
CoP: MEDICATION SAFETY
Contact: ALICE OBORNE
DESCRIPTION: Within medication safety, opportunities exist to reduce barriers to reporting and also strengthen and systematise learning after incidents. Rates of medication incident reporting vary between organisations and is affected by willingness, time and benefit perceived from reporting. The impact on staff groups involved in incidents varies between health professions: nurses may be taken off medication administration immediately whereas prescribers may not even be informed of their errors if another prescriber can be found to correct the prescription. Reflective learning is key to improvement however learning is poorly done and poorly documented in many organisations. Completion of the initiatives planned may be unknown if follow-up of actions or audit is not done.
Reflective learning includes both at the individual level (e.g. early, proactive, written narrative of events) and at a department or organisational level (documentation of learning in incident reporting systems; after action reviews) in many organisations. Better systems for learning after medication incidents may reduce the inequality in repercussions between professional groups after incidents.
CoP: ACUTE DETERIORATION
Contact: MATT IBRAHIM
DESCRIPTION: Acute physiological deterioration is a precursor to most cardiac arrests. We know that 75-80% of adults show signs of deterioration prior to their cardiac arrest (NCEPOD 2012). We also know that the survival outcome from an in-hospital cardiac arrest is poor (7-8%). I believe that we need a collaborative approach to how we facilitate earlier recognition of acute physiological deterioration and look at strategies to avoid cardiac arrest. The data that we have captured demonstrates that Early Warning Scores (EWS) are not always an accurate predictor of cardiac arrests. We have developed an amended cardiac arrest scoring system that we believe is more sensitive and specific that just EWS alone. I would like to foster a whole system, multi Trust approach to acute deterioration that unifies educational, clinical and research domains to improve patient safety.
Contact: DAGHNI RAJASINGAM
DESCRIPTION: The Maternity/Pregnancy CoP will look at post- partum haemorrhage below 1.5 L of blood loss and this is generally less well documented. It is however, on the increase, across the UK and especially so across London. The morbidity associated with this is often unrecognised by maternity teams and primary care due to poor communications between primary and secondary care. Additionally it can adversely affect bonding, breastfeeding, mental health of the mother and be a traumatic experience for both the woman and her partner. The CoP is hoping to explore some of the causes of non-massive obstetric haemorrhage and improve the care that the woman receives before, during and after her delivery in the postnatal period. We anticipate exploring ‘back to basics’ educational bundle for midwives and obstetricians but would also like to improve the care that these women receive after the event, across the traditional boundaries of primary and acute care. I anticipate two ‘core’ communities: one composed of the multi-disciplinary team involved during post-partum haemorrhage and the other to include this team and primary care providers.
The community will look to involve interested stakeholders across South London, using the Safety in Maternity Services (SIMS) (multi-professional) network and the London labour ward leads (medical) networks. We will start the conversations by presenting some of the London data and the pilot ‘back to basics’ (B2B) package that has been developed by Women’s Health at GSTT. As a group we look forward to ensuring the input of women so that we also address what is important to them in these situations. It would be useful to engage educationalists and improvement methodology experts within the community. Whilst the main aim of the CoP will be to impact on the rates of postpartum haemorrhage, we hope that the learning and experiences from the CoP methodology can be documented, disseminated and applied to other areas of women’s health.
Contact: NARANI SIVAYOHAM
DESCRIPTION: Sepsis is a condition that affects many patients and is associated with a high mortality rate. It costs the NHS £2.5 billion a year and it is estimated that 44,000 patients die of it every year (UK Sepsis Trust). It is also estimated that 12,500 of these deaths are preventable. Early identification and treatment has shown to reduce mortality. Although this sounds simple, improving outcome is a multifaceted conundrum. There are many primary and secondary drivers at different levels that require optimising to achieve better outcomes. Many of the drivers are common to many departments and hospitals whilst some may be unique. The purpose to the Sepsis Community of Practice is to improve understanding of the drivers, learn from each other and share a vision.
CoP: DUTY OF CANDOUR (Openness, Honesty Transparency)
Contacts: TONY NEWMAN-SANDERS, YVONNE CONNOLLY
DESCRIPTION: Now that Duty of Candour has become a statutory requirement, there is a danger that organisations focus on ticking the legal boxes rather than the most important aspect of an ethical response to someone who has suffered avoidable harm. The new professional codes help to some extent but given the difficulty of having these conversation with patients and relatives, there is huge scope for sharing ideas and good practice. This Community of Practice aims to articulate the elements of a positive learning culture with patients and their relatives at its heart, which combines support and pastoral care with fair accountability for staff. We would like to explore together:
- How to support staff who have been involved in an incident where harm has occurred.
- How to have conversations that meet the expectations of patients and their families.
- Incident reporting processes
- After event reviews
- Training and Core skills aspects
- Professional self evaluation/appraisal/revalidation
- Performance management and disciplinary aspects
- Pastoral care and support of staff
Please join us as we compile a range of patient and staff stories that can be used as a resource for learning.
Contact: MARK KINIRONS
DESCRIPTION: Delirium is a vital area for learning and improvement. Delirium affects large numbers of people directly, as well as their carers, families, and the health and social care community. We do not currently have an integrated and combined recognition and response pathway, approach, knowledge, action or culture to delirium across the Health Innovation Network member organizations. The Delirium Community of Practice seeks to address this.
The acute sector, which often sees the more advances cases of delirium, has more developed thinking and pathways for those with the disorder. If the healthcare community could intervene earlier in the downward trajectory of patients with delirium, we could improve the experience, quality and safety for all involved, while reducing costs and improving professional satisfaction. The community of practice seeks to address this through working closely with the South London Care and Nursing Homes Network and focusing on staff training.
As the Convener, Dr Mark Kinirons also leads significant clinical teams and initiatives focused on delirium and dementia. Mark brings his connections to networks across South London to his convener role, giving wide access to influence and drive change across the HIN. The Delirium Community of Practice has the possibility to lead change and improvement together through a networked model. This is an exciting opportunity to do things differently for the benefit of patients and those who support and treat them.
Image via Creative Commons