Patient Safety Improvement
Winner
The Newcastle upon Tyne Hospitals NHS Foundation Trust: A collaborative model of meningococcal vaccination response monitoring for patients receiving complement inhibition
Some patients at the National Renal Complement Therapeutic Centre (NRCTC) receive eculizumab, a C5 inhibitor that increases the risk of meningococcal sepsis more than 600-fold. This is mitigated via vaccination and antibiotic prophylaxis but, as patients were geographically disparate, NRCTC specialist nurses noted a deficiency in local monitoring. Working with stakeholders, new service level agreements across all trusts were negotiated and implemented, resulting in an innovative system to increase monitoring of meningococcal titres and revaccination. The scheme’s success has resulted in a wider roll-out.
Finalists
Blackpool Teaching Hospitals NHS Foundation Trust: Operation Provide
NHS-employed independent domesticviolence advisers attended incidents ofdomestic abuse with the police to deliverrisk assessments, safety planning, andemotional and practical help. Havingsupported more than 3,000 people, theinitiative has been launched as a nationalhomicide prevention framework.
Bolton NHS Foundation Trust: Enhanced Care and Support Team
Innovative therapies were offered to
patients at risk of harm due to cognitive
decline, falls and challenging behaviors.
Therapies offered included personal care
assistance, haircuts, arts and crafts, and
music therapy. Huge financial savings
were made, and violent or aggressive
incidents fell by more than 65%.
Dartford and Gravesham NHS Trust: Clinical nurse tutors
To combat a rise in medication errors and
delayed care, clinical nurse tutors were
introduced to educate and support more junior
nurses. Inspiring them to upskill in
their clinical environment proved
successful in improving patient safety.
Kettering General Hospital NHS Foundation Trust: Call 4 Concern: implementation and one-year review
Call 4 Concern was rolled out trust wide to give patients and relatives direct access to critical care outreach services to prevent clinical deterioration and improve their experience. Feedback from service users was overwhelmingly positive and deterioration was reduced.
Kingston Hospital NHS Foundation Trust: Nasogastric feeding tube safety
An adult nasogastric feeding tube audit
and competency assessment pathway
was devised, comprising scenario-based
training, ongoing education, routine
reviews and spot-checks. There are now
more competency-assessed nurses,
better compliance audit data and
improved reporting of near misses.
Lancashire and South Cumbria NHS Foundation Trust: The Bus Stop
To reduce self-harm and aggression/
violence on an acute mental health ward,
the ‘bus stop’ – chairs strategically placed
between communal areas and bedrooms
– became an area where brief therapeutic
interventions, such as relaxation activities,
were delivered to aid mental wellbeing.
Concerning incidents reduced and service
users reported feeling supported.
Medway NHS Foundation Trust: Acute and emergency medicine collaboration to maximise community safety
This project to substantially reduce
ambulance handovers and patient harm
meant building inter-service trust where
relationships had been fragile, or even
hostile. Roles and procedures were
amended, and same-day emergency care
access improved, leading to fewer delays.
Nottingham University Hospitals NHS Trust: Advanced practice governance maturity matrix
A nursing advanced practice (AP) lead
role was established to understand and
implement AP governance to underpin
patient safety across the trust. A maturity
matrix was developed to ensure a positive,
asset-based approach to building a
patient safety culture around AP roles. It
has been adopted by multiple employers.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust: Let’s Get Moving
This quality improvement initiative to
prevent deconditioning in older patients
on Feltwell Ward set out to get them out
of bed and dressed, and enhance their
wellbeing. Innovative methods resulted
in significant improvements in their
functional independence, optimized
patient flow and happier staff.
Shropshire Community Health NHS Trust: Named nurse in community nursing
A new model of care was rolled out in the community nursing service so each patient had a named nurse responsible for their assessments, care plans and treatment reviews. Serious incidents and complaints reduced, patient feedback was positive and staff job satisfaction rose, improving retention.
Spire Healthcare: Reducing the incidence of post-operative hyponatraemia and improving care
Patient safety incident reports showed that hyponatraemia cases were higher than expected after major joint replacement surgery. A new team that was set up to address this developed a nurse training package, and created guidance and prompts for staff . Hyponatraemia cases dropped by 70%.