My Patient Safety Congress

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Hannah Baird, Improvement Fellow and junior doctor working as an ST2 at Royal Bolton Hospital shares her experience at the Patient Safety Congress 2017 attending with our Director of Improvement, Katharine Goldthorpe.

In July I attended the Patient Safety Congress here in Manchester. I have been to a few conferences recently but not one that focused solely on patient safety. I have to admit, I wasn’t sure what to expect. Would it be clinicians, managers, safety experts…?

Opening sessions set scene for the two days, as well as introducing us to their PS congress app where you could not only submit questions online but vote for your favourite questions so they would more likely be asked! We were also introduced to the Healthcare Safety Investigation Branch headed up by ex-airline investigator Keith Conradi.

There were four themes running throughout the day – Human Factors, Leadership, Governance and Risk Management and International Learning. Moving between sessions to experience the variety of the day, my two favourite sessions were complete opposites. The first was delivered by James Titcombe and Jonathan Hazel from Datix, sharing personal stories but highlighting how incident forms need to be used to inform and not to punish or reprimand.

The second session I particularly enjoyed was around resilience, delivered by Chris Lake, former Head of Professional development at the Leadership Academy. He talked about resilience being over expected and unfairly demanded of staff in the NHS. Something I couldn’t agree more with. As an A+E doctor if we have an upsetting or traumatic case we often only get a minute to process that and carry on with the next patient. Not only that but to come to that next patient with a fresh set of eyes and compassion. It can be tough. He explained that by developing our own emotional literacy and consequently our own emotional intelligence we can become better leaders, creating better culture and climates, and in turn more resilient staff.

Walking around at the breaks there were lots of posters being showcased (including mine!!) and it was great to see so many projects across a real range of topics; many using the model for improvement and displaying their data in run chats.

Sir Robert Francis delivered a spellbinding speech focused on how far we have come since the report. He highlighted the changes that have been made, that he believed culture is changing and we are becoming more open without patients. He highlighted, a theme that had run subliminally through-out the day on workforce and the well-being of our staff.

The second day of the conference was an early start going straight into breakout sessions. Our very own Katharine Goldthorpe was chairing with a theme on ‘designing and implementing whole system safety’.

As an A+E doctor I couldn’t resist the temptation to attend a session lead by Leicester A+E department on how they had redesigned their department to improve flow and improve outcomes. They described a process of a complete redesign – a new building, new IT system and crucially a way of overseeing the department in real-time, highlighting areas of concern on risk in real-time, rather than discovering something when it is too late. Interestingly they had incorporated primary care into the department both physically and through IT. Ensuring patients were streamlined to the appropriate service. It sounded incredible and left me wanting to approach the consultant for a job!

The next session was on a similar theme, led by Bristol Consultant Emma Redfern. However, with no opportunity to build a new department, they looked at ways to improve safety in the department by introducing a ‘ED checklist’. A step by step guide to what needs to be done for patients and when from a nursing perspective. They had acknowledged that due to staff shortages, ED was often staffed by agency nurses or nurses ‘borrowed’ from other hospital areas. This checklist aims to give them a guide to ensure basic nursing care was delivered and that sick patients, particularly those without a bed but in the corridors were identified and seen at an appropriate time. A simple yet crucial and effective initiative – which with the help of the local ASHN they have spread across different trusts in the region.

This leads us into the final plenary sessions of the day. Unfortunately the Secretary of State for Health was unable to attend, but did send a video. He talked about the patients who had suffered when safety was compromised and the journey we still had to make.

Finally Sir Liam Donaldson, from the WHO, closed the day delivering the James Reason lecture. Alongside recounting his chance meeting with James Reason, he reiterated to the audience why safety is paramount, and that by ensuring that our systems are safe we can prevent disasters and avoid personal blame. He left us with this quote from James Reason himself:

Either we manage human error or human error will manage us’

 

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