Patient Safety, Healthcare Worker Safety: Two sides of the same coin

Ayobola Chike-Michael, Patient Safety Project Manager at the Health Innovation Network (HIN) shares her thoughts on how safe health care workers means safe patients.

Focusing on Healthcare workers

Patient safety is a global health priority that aims to prevent errors and adverse effects to patients associated with health care (WHO, 2020). Exponential medical development has contributed to healthcare becoming more effective and efficient. However, these new technologies, medicines and treatments, also present ‘wicked problems’ that demand unprecedented and multifaceted solutions. The 17 of September every year has been coined as World Patient Safety Day, set to promote patient safety by increasing public awareness and engagement, enhancing global understanding, and working towards solidarity and action.

The theme for this year is ‘Safe health workers, Safe Patients’ placing the spotlight on health care workers. The biggest threat to the world in recent times, particularly this year is Covid-19, a pandemic that turned health care workers worldwide into soldiers fighting at the war front. Covid-19 has so far posed the greatest pressure on health care workers and they have had to face the challenges daily. Most of these issues have always been there, but the pandemic magnified them and demanded more from every health care worker.

Speaking to a friend who has been a nurse for 25 years recently, she recounted how one day at the height of the pandemic, she was kitted up for protection before entering the ‘Covid-19 zone’ at work. She admitted how unprepared she was despite her years of experience.  She had taken one look at the room filled with sick Covid-19 patients on one side and on another noted body bags ready to be filled. In her words, she said, ‘it was really a war, there was no time to make sense of everything going on’. After a couple of hours of caring for sick patients and managing expectations of relatives, she described how she steamed up under the protective personal equipment, dripping uncontrollably with sweat and finally bursting into tears.

Recent research showed that many have also suffered psychological and emotional distress, infections, burnout, uncertainty, moral injury, violence, stigma, depression and even death (WHO 2020 and Only Human report 2020). The pandemic has brought new challenges and new ways of working and we cannot talk about patient safety in 2020 and beyond, without talking about staff safety first.

Nobody should have their safety impacted at work and we certainly cannot look away from the risks presented to health care workers whose place of work this year, has been more like the war front. These workers not only have to provide care through it all, but they also must bear the outcome of their lived experience. They must be looked after well, during and after. A Yoruba proverb says, ‘if you find yourself and your child engulfed in fire, you must dust yourself first before you are able to dust your child’. That is, ‘the instinct in an accident is to protect oneself before the thought of anyone else, even your child.

“Most of these issues have always been there, but the pandemic magnified them and demanded more from every single health care worker.”

The link between patient safety and worker safety

It’s no surprise, therefore, that there is a firm link between patient safety and health worker safety. The safety of both patients and staff are inextricably linked, like two sides of the same coin. They are co-dependent. Staff safety is a prerequisite to patients’ safety. Only a safe health care worker can ensure a safe patient.

Stress is the first culprit that creates burnout among health care workers and has a significant impact on the quality of care given to patients and their overall safety. The top reasons for stress are high workload, long hours, strained interpersonal relationships and lack of teamwork. These and many more cause health care workers to be more prone to errors and experience a decline in their own health. (WHO/IOSH, 2020).

Let us share some other painful facts:

  • Health workers have the highest risk of Covid-19 infections, in fact, 10 per cent of all cases globally are among health workers
  • Between 44 per cent and 83 per cent of nurses in clinical settings in Africa have chronic low back pain
  • Between 17 per cent and 32 per cent of health care workers in high-income countries suffer from occupational burnout
  • Globally, 63 per cent of health workers report experiencing a form of violence at the workplace
  • Medical professions are also at higher risk of suicide in all parts of the world
  • During the Covid-19 pandemic, 23 per cent of front-line health care workers suffered depression and anxiety and 39 per cent suffered insomnia
  • One in three health care workers in high income countries suffer from work-related burnout at the workplace (WHO/IOSH, 2020).

Recommendations for post-covid recovery

Global players such as the United Nations, WHO, International Labour Organisation (ILO) among others have shared some resolutions to take necessary steps to alleviate some of these painful facts at country level. Other organisations are working equally hard regionally and locally. All have committed to scale up efforts to improve and promote healthier and safer workplaces. Further recommendations have also been made to support global advocacy for health care workers’ safety.

A few are:

Part of the journey to recovery from the pandemic is the intentional focus on the safety of health care workers. It is important before, during and after the 17 of September, to promote patient safety particularly by increasing awareness on this year’s focus – health care worker’s safety. No one is excluded in responding to the global call for action to speak up for health care workers safety. It is directed to everyone:  patient, family, carer, health care worker, local and international organisations, policymakers, regulators, administrators, managers, patient representative organisations and academic or research institutions. All hands must be on deck to promote the safety of health workers.

Never again should any health care worker have to work without adequate PPE, never again should any health care worker be overwhelmed with stress, bear the brunt of lack of resources or face avoidable harm for their patients or themselves. As Tedros Adhanom (Director General, WHO) succinctly puts it ‘Together we have a duty to protect those who protect us.’

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Patient safety and experience: our response to Covid-19

Patient safety and experience: our response to COVID-19

Our Patient Safety and Experience, Healthy Ageing and Digital Transformation Teams have been working in partnership to support our local health and care system response to Covid-19.  Working as part of the NHS National Patient Safety Improvement Programmes, our work over the next six months will focus on the following areas to contribute to the NHS response to Covid-19.

Deterioration

Failure to recognise or act on signs of deterioration can result in missed opportunities to provide necessary care and give patients the best possible chance of survival (Patient Safety Alerts 2016, 2018). This area therefore continues to be a major patient safety priority for the NHS during the Covid-19 outbreak. A good system of managing deterioration includes processes and solutions that enable:

  • Early detection of physical deterioration. This includes a physiology assessment and early warning tools such as soft signs and the NEWS2 score. A growing number of digital solutions to support these processes are also available.
  • An understanding of what is “normal” for a resident.
  • Staff knowing what to do next if a person’s health deteriorates. Agreed escalation processes are required, including end-of-life preferences, advanced care and treatment escalation plans.
  • Staff to effectively communicate their concerns. This includes human factors and structured communication.

We already have a south London managing deterioration improvement programme as part of the national patient safety improvement work. Consequently, our team is contributing to national developments and assisting regional and local efforts aimed at optimising patient outcomes during the pandemic. We are also building connections with a growing number of digital projects aimed at enabling remote assessment and monitoring of patients within the community setting.

Our Programme Director for Patient Safety and Experience, Catherine Dale, is a national co-lead for the Patient Safety Collaboratives on deterioration and was instrumental in the delivery of a very successful national webinar for GPs working hard at the front line to tackle Covid-19.

Our Tracheostomy programme as part of the Patient Safety and Experience team’s wider response to Covid-19. Through the South London Critical Care Network and other local colleagues, we have been exploring what inpatient tracheostomy care looks like currently in trusts and how teams can be supported to improve it and make it even safer during these challenging times. The team are also starting to think about what service provision is available for tracheostomy care in the community, for those discharged from hospital. Find out more about the AHSN Safe tracheostomy care work here.
Our Patient Safety and Experience team is still working in collaboration with Revealing Reality and Hill+Knowlton Strategies, adapting our previous work on Behavioural Insights into Catheter Careto support and protect the health and wellbeing of healthcare staff during the current pandemic. Many staff in the NHS and beyond have found themselves in strange new territory or have been greatly affected by this global crisis. We are applying our experience of Behavioural Insights and Quality Improvement to a new project that aims to support south London staff and equip them to face the challenges ahead.
Care and outcomes for women and babies remains a priority during the pandemic. The team has been working with local trusts, as well as teams nationally, to support the sharing of intelligence and spread of innovations with the aim of maximising learning and improving safety.

We are supporting four units in south London to adopt a standardised assessment and triage system called The Birmingham Symptom-specific Obstetric Triage System (BSOTS). This provides a framework for women to be assessed quickly and reliably when presenting with concerns and those who need urgent care are prioritised, rather than reviewing women in order of attendance.

We have also been supporting the spread of the QUiPP app – a locally born clinical decision-support tool that helps to predict the likelihood of preterm delivery when a woman presents at hospital. The supporting toolkit for adoption has been rapidly rolled out during the pandemic as this innovation helps to decrease unnecessary admissions and transfers.

In partnership with our London colleagues, we have also begun to consider safety practices and cultures in maternity and neonatal care in the coming months as we enter the next phase of the pandemic.

There is evidence that patients who have information about their medicines when they are transferred to their usual community pharmacy are less likely to be readmitted to hospital. In the current Covid-19 response, with large numbers of patients being discharged quickly, it is imperative that medication safety is not overlooked. TCAM schemes are a structured way to pass on medicines information from hospital settings to community pharmacies. Trusts that already have TCAM schemes in place are asked to review their referral criteria to make sure patients at the highest risk and with the greatest need are prioritised.

We are are working with trusts who are yet to establish TCAM schemes by engaging with hospital pharmacists, community pharmacists and local pharmaceutical committees (LPCs) in those areas.

“High quality, safe care can be achieved through preparation, planning and education; the National Patient Safety Improvement Programme has created this important national program to rapidly develop the skills and knowledge for bedside staff to deliver safe tracheostomy care everywhere.”
Brendan McGrath – National Clinical Advisor for National Patient Safety Improvement Programme Covid-19 Response (Safe Tracheostomy Care); Intensive Care Consultant, Manchester University NHS FT

The team will be very happy to hear from you if you want to know more about any of our projects above or discuss support for your local work, contact hin.southlondon@nhs.net

You can also access nationally available resources and webinars on the AHSN Network Patient Safety COVID-19 webpage here.

Helping break unwelcome news

Helping break unwelcome news COVID-19 outbreak

Health Education England has published a set of materials and films which aim to support staff through difficult conversations arising from the Covid-19 outbreak.

The AHSN Network was part of a small group of people that helped pull this resource together in less than two weeks.

The framework includes posters and films based on the evidence base from Real Talk and then filmed with willing volunteers.

You can also follow #UnwelcomeNews on Twitter.

Start here for an introduction to the framework: Discussion of Unwelcome News during the Covid-19 pandemic: a framework for health and social care professionals

You can watch the films here:

  1. The framework
  2. Community
  3. Breaking bad news
  4. Ceilings of treatment

Then access the resources here:

Follow this link for more information on patient safety during Covid-19.

Covid-19: Patient Assessment the role of physiology and oximetry

COVID-19: Patient Assessment the role of physiology and oximetry

The assessment of patients who are unwell with Covid-19 or other causes presents a significant challenge for GPs and clinicians working in Primary Care. The Royal College of General Practitioners (RCGP) and the AHSN Network are holding a joint webinar looking at the role of oximetry and other physiology in that assessment.

The webinar will be led by:

  • Dr Jonathan Leach, RCGP Honorary Secretary and Covid Lead
  • Dr Alison Tavaré, Primary Care Clinical Lead at West of England AHSN
  • Dr Simon Stockley, RCGP Lead for Acute Deterioration and Sepsis

Overview of content to be explored:

  • Clinical features of Covid-19
  • Importance of oximetry in Covid
  • Clinical judgement and physiology in Patient assessment
  • Role of NEWS2 in General Practice and Care Homes
  • Remote oximetry in the assessment and management of Covid disease in the community
  • This will be followed by a Q and A session.

The webinar will be held on Wednesday 29 April, 13.30 – 14.30pm and you can register here. The webinar will be recorded and shared afterwards.

Preventing prescribing errors in south London with PINCER

Over the past fortnight, almost 90 GP pharmacists have taken part in training on software that aims to reduce prescribing errors. PINCER searches GP clinical systems using computerised prescribing safety indicators to identify patients at risk from complications that arise owing to being prescribed multiple medicines that don’t always work together and then acting to correct the problem. The training sessions mean that GP Pharmacists in eight south London CCGs can now use the software in their practises.

“I can’t wait to use the PINCER too, to help reduce errors and adverse reactions. This will help complement our role as clinical pharmacists.”Reena Rabheru-Dodhy, Senior Primary Care Pharmacist

Prescribing errors in general practice are an expensive, preventable cause of safety incidents, illness, hospitalisations and even deaths. Serious errors affect one in 550 prescription items, while hazardous prescribing in general practice contributes to around 1 in 25 hospital admissions.

Outcomes of a trial published in the Lancet showed a reduction in error rates of up to 50% following adoption of PINCER – a pharmacist led system which acts as a risk assessment tool to identify and flag errors in general practice prescribing.

These original PINCER indicators have been incorporated into National Institute for Health and Care Excellence (NICE) Medicines Optimisation Clinical Guideline (May 2015).

Mandeep Butt, Communities of Practice, who is part of the Health Innovation Network team coordinating the training was delighted by the response from the trainees:

“I look forward to working with the amazing practice based pharmacists and technicians we have met over the last 2 weeks. Their enthusiasm was infectious!” The trainees

More about PINCER:

Developed by The University of Nottingham, the PINCER intervention developed as part of PRIMIS audit tools is led by primary care pharmacists and pharmacy technicians.

With funding and support from the Health Foundation and East Midlands AHSN, PINCER was rolled out to more than 360 practices across the East Midlands between September 2015 and April 2017.

This involved:

  • Using software to search clinical systems to identify patients at risk of hazardous prescribing
  • Conducting clinical reviews of patient notes and medication
  • Carrying out root cause analysis and providing feedback to the practice
  • Establishing action planning to improve systems and reduce risk
  • Establish action planning to improve systems and reduce risk
    Scale up PINCER using a large-scale Quality Improvement Collaborative approach
  • More than 2.9 million patient records were searched, and 21,617 cases of potentially hazardous prescribing were identified

The programme is one of the interventions selected for national adoption and spread across the AHSN Network and has so far demonstrated great results in a preliminary study, where there was a significant reduction in hazardous prescribing for indicators associated with gastrointestinal bleeding, heart failure and kidney injury.

Further information

Further training sessions will be happening in May and June. For more information or sign up for the training, please contact us.

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If you have any questions or would like more information about PINCER. Please contact us.

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World sepsis day – watch our ‘Spotting sepsis in under 5’s’ film

Share our vital film on World Sepsis Day

Sepsis kills 44,000 each year in England and research shows that identifying it and acting on it quickly can save many lives. Our Spotting sepsis in under 5’s is a a vital tool in spotting the condition in the very young.

Today marks World Sepsis Day, a day to raise awareness about the dangers of sepsis. A life-threatening reaction to infection that can result in tissue damage, organ failure and death.

Spotting the signs of sepsis early and being treated as quickly as possible can lead to a full recovery and gives the patient the best chance of survival, every minute counts with this condition. https://www.youtube.com/watch?v=FifBm_08RkA

Find out more about the signs and symptoms of sepsis at NHS UK .

And we have some great information on our website telling you all about sepsis, the incidence in South London and worldwide.

Help save lives by raising awareness and being alert to the signs and symptoms.

We have had reports of two lives that have been saved directly because of an intervention prompted by the person viewing the Spotting sepsis in under 5’s film.

Creating waves across the Pond

Creating waves across the Pond

Written by Catherine Dale, Programme Director – Patient Safety and Experience.

My friend gave the opening keynote speech at this month’s Institute for Healthcare Improvement (IHI) National Forum in Orlando, Florida. I was moved to tears in the audience watching her.

I got to know Tiffany Christensen this April when we both taught on the IHI’s inaugural Co-Design college in Boston, Massachusetts. I was teaching the Experience-Based Co-Design approach. Tiffany shared her insights both as a life-long cystic fibrosis patient and as a professional patient advocate with a working career in healthcare improvement.

Tiffany spoke of contending with a double lung transplant which was unsuccessful, meaning she was facing imminent death. When offered a second double lung transplant, Tiffany was initially completely thrown as she had accepted the fact that she was going to die. Being offered another chance of life was an enormous challenge to her, but in coming through that experience Tiffany chose to dedicate her working life to enhancing healthcare for others. She joined a Patient and Family Advisory Council – a core part of healthcare structure in the USA – and trained in improvement methods.

When we met at the Co-Design college, she was struck by the way that Experience-Based Co-Design enables patients to have a more active and influential role in improving healthcare. This reminded me that when ‘patient involvement’ became a buzz phrase in the NHS in the early 2000s I had often wondered ‘involvement in what?’ you can’t just be ‘involved’ without context or purpose. For me the most compelling area for patients to be involved in is improving and re-designing healthcare. I am biased as this is the field of work I have devoted myself to for the past decade and a half. But I find it so rewarding that I want to provide others with that same opportunity – hence training people in Experience-Based Co-Design every chance I get!

Tiffany and I delivered a workshop ‘Co-design is Caring: Experience Meets Experience’ at the IHI National Forum with Andrea Werner from Bellin Health in Wisconsin. The participants were extremely enthusiastic about the approach. One tweeted “It was amazing! It’s all about the ‘we’ not ‘me’ – value and include the voice and experience of patients!”

It was fantastic to have this opportunity to share and encourage co-design between staff and patients. So I was incredibly proud that ‘co-design’ was a core message in the keynote discussion between Tiffany, Derek Feeley and Dr Rana Awdish

When Tiffany gave her closing thought in her keynote I found myself gently weeping: we should not consider our efforts to improve healthcare to be drops in the ocean, every one of us is a ripple and we don’t know how far that ripple will have an effect.

If, like Derek Feeley, CEO of IHI, you would like to see healthcare evolve from patient-centred care to partnership with patients you can start here or contact me for further encouragement. If we add all our ripples together we will create waves.

Pictured above: Tiffany Christensen (left) and Catherine Dale (right)

Note: Many thanks to the Point of Care Foundation, IHI and the Health Innovation Network for enabling me to attend the IHI National Forum in December 2017.