Patient Safety Improvement

High-profile care failings, such as those at the former Mid Staffordshire NHS Foundation Trust and more recent examples, have illustrated what happens when patient safety is not seen as a key priority, while winter pressures combined with severe nursing shortages often lead to concerns that safety is being compromised. As the professionals with the greatest amount of patient contact, nurses play a vital role in ensuring patients’ safety at every stage in their care.This category is open to individuals or teams from the NHS or independent sector who have undertaken an initiative to address factors that place patients at risk and promote safety as an essential part of healthcare. Entrants should have clear outcomes demonstrating improvements in patient safety.

Birmingham Women's and Children's NHS Foundation Trust
Reducing extravasation incidence and harm levels

Extravasation is a nationally recognised complication of IV administration (NHS Resolution, 2022). With a severe-harm incident every 6-months, a moderate-harm incident every 3-months and 15.4 low-harm incidents every month, it was also an area of care Birmingham Women’s and Children’s NHSFT urgently wanted to improve. A nursing-led, multi-disciplinary team developed an ergonomically designed extravasation care bundle; combiningan innovative RAG (Red, Amber, Green) extravasation rating of all IV medicines with an enhanced approach to observing IV access sites and tracking of IV infusions. This bundle empowered bedside nurses to tailor infusion administration according the extravsation risk of the infusions whilst simultaneously providing them with enhanced IV site monitoring and escalation guidelines, This reduced severe-harm to 0, reduced moderate harm incidents by 46% and reduced low harm incidents by 33%In addition to reducing patient harm, this has led to reducing average legal costs by £346,797 pa, investigation costs by £30,540 pa, PICU bed usage by £15,845 pa and theatre costs by £5,965 pa.. The first difficulty was the lack of high-quality evidence to address the risks associated with IV medicines administration. This meant the innovations developed required BWC to start from scratch. The second difficulty is that due to the innovative nature of this work, BWC have been unable to identify an external expert to validate the extravasation risk rating. This PhD level study is one we are currently persuing with a local university. In addition to the validation study mentioned, BWC are collaborating with external experts to develop technological solutions to further reduce incidence and harm.

Bolton NHS Foundation Trust
Introducing more virtual care with our admission avoidance team

Our Admission Avoidance Team (AAT) is predominantly nurses, though they work collectively as part of a large multi-disciplinary team (MDT). The team has been at the forefront of driving the adoption of ‘virtual wards’ in Bolton, introducing models of virtual care ahead of the national ‘Hospital at Home’ initiative being introduced. In order to support more people to receive the care they needed at home, and relieve pressures on acute hospital beds, the team developed a programme of work to consider how we could support the aims of virtual ward on a larger scale. Supported by colleagues from a range of disciplines, the team originally concentrated on a step down approach from the hospital setting, rolling out a pilot with the frailty ward. Through a team member attending the MDT, relationships were developed and a greater understanding was gained of what we could offer in facilitating earlier discharge. The success of the full initiative then led to a roll out to other wards including same day emergency care (SDEC) and critical care. However, we had to overcome a lack of understanding about virtual wards, lack of electronic patient records in the community and no dedicated consultant support. We also had to meet the 2-hour urgent care response. We had already identified issues for patients who had fallen, resulting in a wait for up to nine hours for an ambulance. By sourcing a lifting cushion, this supported the falls pick up pilot, working with North West Ambulance Service (NWAS) we have successfully been able to respond to patients within one hour. Our nurses provide a comprehensive falls assessment to determine whether a patient is fit to remain at home, signposted to other services or be admitted to hospital. We continue to develop our offer, consistently achieving national and local targets.

Calderdale and Huddersfield NHS Foundation Trust
Neuroendocrine tumour CNS service

An oncology nurse identified that there was no site-specific specialist nurse for patients living with or being treated for neuroendocrine cancer (NET) patients at a District General Hospital (level, despite treating a significant number of patients within the local area. This meant that they had no specialist nursing support or access to Macmillan Holistic Needs Assessments, that there was extremely limited awareness of the illness and that they are at risk of Carcinoid Crisis, which is a life-threatening complication. Following the nurse's voluntary pilot study, business case and championing this cause for two years, Macmillan, kindly pump-prime funded their project for a NET Specialist Nurse service at the local trust. The service has shown an increase in support for the patients, with nurse-led clinics, early intervention to speed up a complex diagnostic process and support patients through this. Alert cards and information, and the service phone number for support and nursing assessment were provided. Following the success of this service, from a qualitative and quantitative perspective (see attached) a clinical need has been identified and application has begun to continue this, a further DGH trust is also considering utilising this initiative. All patients were screened for nutrition and around half were at risk of malnutrition. The nurse worked with external dietetic professionals, to improve outcomes, and, to detect Pancreatic Enzyme Insufficiency and prescribe Creon for those where appropriate as >10% of patients were identified following assessment. An local education package has been created and utilised, to help local medical professionals recognise, prevent and treat life threatening emergency symptoms of neuroendocrine tumours. In the coming months the initiative aims to work further with diagnostic services and provide education to GP's to raise awareness, to help to improve early diagnostics, to further improve outcomes.

East London NHS Foundation Trust
Improving observations and therapeutic engagement on mental health inpatient wards

Therapeutic engagement and observations are a key part of keeping service users and staff safe on inpatient mental health wards. In 2021 East London NHS Foundation Trust (ELFT) received several Prevention of Future death notices that highlighted that observation practice needed to improve. In 2022-2024 ELFT used quality improvement (QI) across all 52 wards to improve engagement and observations in response to several Prevention of Future Death notices. ELFT uses quality improvement as its method for tackling complex problems. Staff and service users were supported to use QI to develop co-produced local projects to understand the issue, develop a set of change ideas and test the ideas iteratively on a small scale using Plan-Do-Study-Act-Cycles (PDSA). To be able to take ideas that have been seen to work and scale them across the Trust, the IHI framework for scale-up and spread was therefore used here. Following testing of local change ideas, staff and service users then came together to agree on three ideas to test for scale up across the organisation. These included:1. A board relay: where an observation board is handed over between staff.2. Zonal observations: dividing the ward into zones where staff are allocated to engage with service users.3. Use of life skills recovery workers to provide engagement on twilight shifts. As a result of the work there has been improved reliability in observation completion and reductions in incidents of violence and restrictive practice Trust-wide. This work had several challenges:1. No standardised way to collect observation data.2. Taking local ideas that worked and scaling them across an organization.3. Maintaining energy and buy-in for the work. This work has now moved to implementation across the organisation, with teams supported to develop quality control systems and work monitored through local and central governance systems.

Humber Teaching NHS Foundation Trust
Emergency department mental health streaming

There is mounting evidence suggesting that an Emergency Department (ED) is not an adequate or effective environment in for individuals in a mental health crisis to receive support. Patients report negative experiences which are likely due to over-crowding, over-stimulating and time pressured environments. These negative experiences are likely to contribute to why patients choose to leave prior to Mental health assessments and safety plans being put into place to support them upon discharge. The MHLS recognised the need to deliver care and support to patients in an environment that is welcoming, trauma-informed, and clinically safe. Based upon the streaming principles in line with the NHS Long term plan, Mental Health Liaison Service (MHLS) launched a new service initiative in June 2023 which involved streaming patients away from the Emergency Department (ED) when clinically safe to do so, to a co-located Mental Health Streaming Area which has been named ‘The Humber Suite’. Throughout the development and design of the streaming initiative, stakeholder engagement was viewed to be imperative to its success. We held staff engagement meetings to gain their insights and ideas alongside the involvement of patient and carers to gain their valuable opinions and work continues with them to ensure continual improvements can be suggested and implemented. Despite this initiative being in its first year of operation, we have been able to identify its success and areas for further potential. Our future ambition for Mental Health Streaming would be to have Non-Medical Prescribers based within the Humber Suite which would allow us to prescribe necessary medications, preventing the need to transfer back to the ED. We also plan to increase the amount of Approved Mental Health Practitioners in the team which would assist in the reduction of long waits for those patients waiting for a formal Mental Health Act Assessment.

King's College Hospital NHS Foundation Trust
Establishing a new standard method to assess the effectiveness and improve the environmental cleaning in an acute NHS hospital

Environmental cleaning is paramount in minimising and preventing hospital acquired infections. It is the responsibility of the healthcare facility to ensure high standards of the environmental cleaning. However, there is a lack of standard process to check and assess cleaning effectiveness. Inadequacy of cleaning will have an impact on the delivery of the service and put patients at a greater risk of acquiring infection. A project was initiated aiming to improve the practice of the cleaning staff. A survey was carried out and helped identify gaps and establish the focus of the intervention. An invisible fluorescent gel was used as the method of assessment in conjunction with the traditional visual inspection, feedback and education. Ten high touch areas around the patient’s bed space were identified where the fluorescent gel was applied and these were checked using a portable ultraviolet torch on a weekly basis. The gel must be either partially (at least three quarters of the gel) or completely removed for the surface to be considered clean. The survey showed that there is a need for further training for staff and they feel that their role is not valued, hence morale is quite low. At the initiation of the project, the cleaning compliance rate was 27% only. Regular assessment, education and feedback was commenced. At the end of the project, the compliance had increased to 91%. In addition, the staff morale had increased and they now feel more valued. This is demonstrated by the improvement in quality of cleaning they have consistently delivered throughout the duration of the project. The intervention has definitely improved and sustained the quality of environmental cleaning. To further measure its effectiveness, I will be looking at the number of hospital acquired infection in those areas if the acquisition is lower post-intervention.

Mersey Care NHS Foundation Trust
The HOPE(S) model

Long term segregation (LTS) is a highly restrictive practice which evidence indicates causes physical and psychological harm and trauma to people in services, both as patients and staff. To address this the National Director for Learning Disabilities and Autism invited Mersey Care to establish a programme with NHS England to adopt the HOPE(S) model developed at Mersey Care Foundation Trust nationally at scale. The aim of the HOPE(S) programme is to enable culture and practice change by building capacity and capability in the system to end the use of long-term segregation and improve patient safety. It has deliverable outcomes for individuals, their families and carers, NHS funded organisations and the wider system. Sixteen senior practitioners on a three-year development programme work within the geographical range of their own region. Each year, NHS England identify individuals who are subject to segregation in NHS funded inpatient hospital settings to receive support from the programme. A National Oversight Group for the HOPE(S) programme co-chaired by Sir Norman Lamb and Gavin Harding MBE provide oversight of programme deliverables. The outcomes achieved to date has been through collaboration with people with lived experience, front line staff and system leaders to create the cultural change required across in-patient services to end the use of long-term segregation which is traumatic and damaging for all involved. Since May 2022, the programme has supported 89 people in long-term segregation. Of these people 63 receiving support from the programme have progressed out of LTS (71%).In terms of future plans, the programme has demonstrated its replicability and scalability through supporting 86 people in 31 NHS Commissioned organisations nationally, across 56 hospital sites and has supported 4 community providers to ensure safe transition of people from long-term segregation into their own homes in the community and prevent re-admission to services.

North Devon Hospice
Hospice specific safe staffing tool

Since 2013, assurance around safe staffing has been high on the national agenda. Whilst safe care toolkits have been created, there is no established tool for hospices to measure safe staffing in either an inpatient or community setting. As patient complexity increases, we need assurance that patients receive the right level of care resource in a dynamic and agile way. We therefore developed our own toolkit with a number of patient acuity levels and descriptors based on outcome measures. Each level is assigned a number of care hours that a ‘typical’ patient at that level would receive in a 24 hour period. Patient acuity is recorded daily and, taking into consideration nursing hours on the roster, this creates a utilisation score for the teams. We use the toolkit to support our inpatient unit, Hospice to Home and Community Nurse Specialist teams. We also have adapted it to work as an overarching caseload management tool for the CNS team. Resistance to change was a challenge. Staff were initially sceptical and concerned that it would be used to prove they were not busy rather than support how busy they were. Communication, training and engagement have been key to addressing this as has using the data to support two successful business cases. As a new tool, it has taken some tweaking to get our care hours per day correct, made more complex since Covid with our baseline patients changing from unstable to deteriorating, requiring the tool to be recalibrated. Clinical teams now share a common language when making evidence-based decisions about admissions and managing their caseload. We have a mechanism to evidence staff concerns about patient safety and workload/wellbeing. We can triangulate nursing professional judgement, audit and acuity data to evidence the need for additional nursing time, leading to an investment of 4.5.

Royal National Orthopaedic Hospital NHS Trust
Delayed wound healing in complex hind foot surgery

Delays in wound healing is a post-operative complication that leads to increased costs, repeated appointments and unsatisfactory patient experience. Due to an apparent increased in delayed wound healing we conducted an audit using prospective data collection to identify contributing factors. As Clinical Nurse Specialists (CNS) within the foot and ankle unit (F&A) our role is to see all two week post-operative patients for skin check, removal of sutures and to support patients on their recovery. A previous audit showed there was no link between suture material, dressing type and wound problems. However, it was identified that patients with fragile skin needed wound assessment at one week post-surgery. It was noticed that other factors may have influenced outcome such as complex cases and comorbidities. Therefore we aimed to determine if our wound complication rate is higher than normal (Evidence 1) and to identify causes for this. A prospective audit was completed. A total of 109 adult patient’s data who had undergone F&A surgery over a period of four months was collected. The expected standard was for 90% of surgical wounds to be healed in two weeks post-surgery. Wound healing rates for less complex cases met our audit standard. However the complex cases (15 patients out of 18) had a 20-fold increase in delays in wound healing. Units undertaking complex work should be cognisant of the associated increased burden to patients and clinic time. Having a Multidisciplinary team approach with patients having access to helplines and nurse led wound clinics is essential in this complex group. Having a dedicated CNS clinic allows quicker access for patients when needed in their recovery process. This provides continuity of care as well builds up relationship with their families/carer.

Tameside and Glossop Integrated Care NHS Foundation Trust
The delegation of insulin administratio

I would welcome the opportunity for Tameside to be recognised for the delegation of insulin administration, that has prompted discussions and roll out of the programme in other trusts. We were the first organisation nationally that successfully delegated insulin administration to carers, from both residential homes, assisted living and domiciliary care. Many patients in the community are cared for by the district nurses, and one of the tasks includes diabetes care management. This involves checking blood glucose and administering time critical medication, such as insulin. This task must be completed before meals, to gain an accurate reading of the blood glucose levels. Because of the rising demand for insulin among patients in the community, nurses find it challenging to reach patients promptly. Consequently, patients are left waiting for district nurses to arrive, posing a problem especially for those who prefer early mornings. This could also result in poorly controlled diabetes. Additionally, recruitment and retention issues may lead to patients having different district nurses, ultimately causing a lack of continuity in their care. The delegation of insulin administration is the teaching and training of care staff workers from care homes and domiciliary care. The delegation works across both health and social care services to empower,educate and implement the programme, which promotes the upskilling of care staff workers. The work is having a positive impact on the district nursing service, as it releases time for the nurses to support more complex patients in our community. Utilising the delegation of care programme and the continued support of the district nursing teams with our carers, has improved working relationships and better communication between services for those we care for. The carers now have more knowledge and skills to provide care and most importantly, the patient’s care is better managed in their own home.

The Christie NHS Foundation Trust
Addressing skin tone bias in wound care

During skin assessment patients with all skin tones should receive an equitable level of assessment. Dark skin should not be seen as a ‘challenge’ in clinical practice (Wounds UK 2021),The aim of the project was to provide clinicians with practical guidance to aid accurate assessment and diagnosis of skin changes in all skin tones. During the early stages of implementation, discussions focused on establishing a baseline area for skin tone assessment. The Best Practice Statement Wounds UK 2021 recommends using the patient’s inside upper arm and choosing a skin tone. However, there was some debate about whether baseline assessments should include different anatomical locations on the body. Eventually, it was agreed that assessing baseline in multiple locations was impractical and that the inside upper arm should be used instead. Nonetheless, the importance of inspecting a comparable area of skin for reference was emphasised. For example, when examining the heel for a potential pressure ulcer, it is important to also examine the other heel whenever possible, as differences in skin tone between areas such as the soles are common. As print quality could affect the validity and accuracy of the skin tone assessment tool, ensuring high-quality print files for skin tone documents became crucial. The material of the cards was also considered important because it had to comply with Trust infection prevention guidelines. Changes were implemented in high-quality printing to ensure skin tone colours were accurate, and adjustments were made to the material of the cards to ensure they could withstand decontamination. The Christie Hospital’s future developments involve including it in their incident reporting tools, specifically DCIQ. This strategic initiative aims to facilitate the auditing process for both the incidence and prevalence related to skin-related incidents within their setting.

West Hertfordshire Teaching Hospitals NHS Trust
Surgical virtual hospital for elective colorectal patients

Our clinical lead for surgery delivers one of the largest volumes of robotic surgery in the country and promotes regional and national robotics strategies. Our robotics and Enhanced Recovery After Surgery (ERAS) programmes have contributed to a successful colorectal service at WHTH. How could we improve the service and reduce our post-operative stay even further? Could we improve patient satisfaction and experience while challenging the status quo? To do this, we constructed a surgical virtual hospital model for elective colorectal patients. The Trust operates a pioneering medical Virtual Hospital (VH), so we collaborated with them to add elective surgical patients. We met weekly with VH service leads and a project management team. We held stakeholder focus groups and consulted a patient representative throughout. A retrospective audit revealed that in six months we could have saved 22 beds. We established robust guidelines, pathways and policies to ensure the safety and effectiveness of the project. Hub nurses, ERAS nurses, and a colorectal team clinically managed patients to deliver integrated care under ERAS nurse supervision. The ERAS nurse would identify suitable patients pre-operatively and reassess post-operatively to ascertain if they met the strict inclusion criteria. Engaging the colorectal team in decision-making and sharing our data and experiences helped us overcome our key barrier, which was engagement from the wider team. Patient buy-in was also initially challenging however our comprehensive patient information leaflet helped to remedy this and we quickly gained patients' trust. Our data shows that we have saved 30 beds since November 23, surpassing our original target. 100% of patients felt comfortable and 100% believed VH was a better option. Our long-term goal is to do same-day discharge colectomies, which may be achievable because of our VH. We also intend to expand our service into other surgical divisions, followed by emergency care.