Campaigns and success stories for PSL

Although only three years old, Patient Safety Learning has already established thriving communities of practice and has run some very successful initiatives including a campaign to improve outpatient hysteroscopy services and a scheme to support staff involved in serious incidents, according to Helen Hughes, Chief Executive, Patient Safety Learning.

PSL has now been in existence for just over three years and so designing the Hub has been an important milestone. “Hearing from people that are using the knowledge they find on there, engaging in communities of practice, sharing their experience and then applying it for improvement – that’s the main impact – the fact that we can actually support people deliver change and improvement”, says Ms Hughes.

Two examples of success stories illustrate the achievements of the PSLH; one is staff-related and the other is patient-related:

Claire Cox, a patient safety manager at King’s Healthcare, and a couple of other colleagues created a network of people working in patient safety. “They wanted to engage with others to share their experiences, to ask for help, to invite experts in, to create a community of interest [or] community of practice.  In the year that we’ve been supporting them through the Hub and through various other means they’ve grown to be over 620 members”, explains Ms Hughes.  A weekly ‘drop-in’ session has been established and this regularly attracts large numbers of participants. A recent meeting had over 140 participants. Sometimes external experts are invited when group members have identified the need for specialist input. Already there is “a plethora of examples of how people are learning and improving what they do around patient safety in their organisations”, she adds.

The Hub is also used to share knowledge about risk and about good services. An example here outpatient hysteroscopy services. More than 20 percent of women who undergo outpatient hysteroscopy experience significant pain. “That level of pain is quite shocking – the services that that are private provided by some organizations do not meet Royal College guidelines”, says Ms Hughes.  The patient groups involved have been sharing their experiences and telling their stories. “We use the Hub to help capture those stories and those experiences so people can use that to inform, engage and influence…….. There are hundreds of women’s personal experiences on there. We’ve had those pages viewed over 99,000 times now from around the globe and we are getting feedback that people are pleased that they’re able to source what good practice looks like and they can make sure in their own care that they are getting the services that they should be”, she explains.

Second victims

“‘Second victim’ is a term that was first coined many years ago by a colleague of mine, Professor Albert Wu, in the [United] States and I think even he now says maybe that’s not the best phrase to use. …… but what he was doing was highlighting an inadequacy ….. in recognizing how traumatising being involved in unsafe care can be for staff members”, says Ms Hughes.

Health care professionals are usually committed, dedicated individuals who sometimes find themselves in situations where a series of system errors culminate in patient harm.  “People that have been involved in serious safety incidents, you know, have been so traumatised some people will never work again – some people carry the guilt with them for years”, she says.

She recalls working with a very senior consultant who carried in the inside pocket of his jacket a list of all the patients who had been severely harmed or had died under his care. He said, “I never want to forget them but I never want to forget how I failed them so that I continue to improve”. Despite the obvious guilt and pain, this was a positive response to serious safety incidents.  “What we’ve been doing with many experts in this field is bringing together really what is good practice – how should staff be supported at the time where there may be an incident that is very severe. How are people comforted?  How are people helped to get home safely  …. that they’re not put into a car and driving on a motorway when they’ve had something really traumatic happened. [And then] when there is undoubtedly the necessity for a review or an inquiry they’re being treated with courtesy, with dignity, with support – they’re not being vilified, they’re not being blamed. They are being encouraged to give their opinion of what went on – that insight informs understanding of the causal factors. ….. Staff are encouraged to contribute to any understanding but they’re supported in terms of their own personal and psychological health and well-being”, says Ms Hughes.

Helen Hughes has held leadership roles in healthcare in the UK and the WHO, the National Patient Safety Agency, Equality and Human Rights Commission, Parliamentary Health Services Ombudsman and the Charity Commission. Helen’s previous leadership roles in patient safety include, Director of Operations of the National Patient Safety Agency and \executive lead of the global ‘Patients for Patient Safety’ programme at the WHO.

Patient Safety Learning’s the hub is an award-winning platform to share learning for patient safety. It offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety concerns and how to address them. Membership is free – you can register at www.pslhub.org.

Read and watch the full series on our website or on YouTube.