Safety Culture

The NHS as a whole has yet to achieve the right safety culture and there is much we can do, in all areas of work, to develop a collective ‘mindfulness’ towards safety and for delivering safe care.

There are many factors that help grow a safety culture. These include;

  • Stable and inspiring leadership that listens to the voice of staff and patients
  • Safety as a top priority
  • An engaged and empowered workforce
  • Excellent team work and communication
  • Just Culture and psychological safety
  • Shared responsibility and individual accountability for delivering safe care.

The Patient Safety Collaborative (PSC) has a great platform to support Culture work across the country. The NENC PSC culture work in 2018/19 will focus on supporting Boards to understand the role of leaders in shaping a positive safety culture, supporting organisations to be able to measure culture and take actions to drive improvement.

Completed Projects

Please find below a selection of projects which are now complete:

Implementation of a system to learn from patient and relative experiences of safety following transfer into care homes

Project lead: Lesley Young-Murphy (NHS North Tyneside CCG)

Transfers into care homes are high in risk, particularly where the resident crosses organisational boundaries.

To improve safety there is a need to collect information on incidents and experiences of safety that relate to the care transfer. Different approaches to safety in health and social care result in missed opportunities for shared learning to improve the quality of care received when transitioning between services, and there has been a lack of learning from experiences, particularly across organisational boundaries. It is also important to take into account the resident’s experience of their safety during the care transfer as they have a unique perspective of both their own safety and their care transfer. As such, they are able to act as an additional safety barrier against hazards where they are sufficiently involved.

The aim of this project is to implement a safety survey into care homes for residents, relatives and carers (RRCs) to provide feedback on their safety experiences following a care transfer into the home. This will include developing and implementing an electronic version of a previously validated safety survey for care transfers. Action learning meetings for care home staff and NHS Trust staff involved in the transfer process will be coordinated to learn from RRC feedback, and these will be evaluated to understand how the RRC feedback and action learning meetings have led to service improvement across the transfers of care interfaces, and how the feedback tools can be spread and adopted across the care home sector.

Evaluation of the impact of a Pharmacist Independent Prescriber (PIP) in a clinic setting within a Learning Disability Community Treatment Team (LDCTT)

Project lead: Claire Thomas (Northumberland, Tyne and Wear NHS Foundation Trust)

This project is a collaborative initiative between Northumberland, Tyne and Wear NHS Foundation Trust and Sunderland University to evaluate the impact of a pharmacist independent prescriber on the care of people with a learning disability.

This is a unique clinic setting identified through the demands placed on community care provision recommended by the Winterbourne View report 2011. This is against a backdrop of recruitment issues with Consultant Psychiatrists and the project aims to demonstrate how the pharmacist can release Psychiatrist’s time while maintaining patient care through enhanced medication review.

A second theme of Winterbourne was the over medication of people with learning disability, autism or both in relation to behavioural management. The pharmacist is co-ordinating a review of this inappropriate prescribing and identify a clinic process to support this work. This is in line with the NHS England STOMP (Stopping Over Medication of People with a learning disability, autism or both) campaign and the work will be shared nationally.

The evaluation process will be quantitative in terms of interventions made and medical time saved together with team statistics including discharge rates and medication incident reports. A qualitative arm will focus on the opinions of staff within the team and feedback from carers of the service users.

Mental Health Nurse Provision in Cleveland Police Force Control Room

Project lead: Allan Fairlamb (NHS South Tees CCG)

Cleveland police experience a large amount of calls per day (1100-1200). Around 48% of these calls have a mental health marker. When the police are using the “THRIVE” risk tool, a mental health marker can influence the priority a call is given and any police action taken. Lack of timely information and advice can mean Police can be deployed to events which do not require Police presence or inappropriate intervention is used e.g. individuals being held under S136 when they don’t need to be or individuals are taken to A&E.

This project will allow a mental health nurse to be stationed in the Force Control Room (FCR) to provide call handlers and officers on the ground with expert mental health advice and information about individuals that are currently known to mental health services. This will allow for an improved response to mental health, self-harm/suicide and mental health public safety concern related calls.

The project is being approached in a collaborative manner through the Tees Crisis Care Concordat and has gathered funding contributions from Cleveland Police, Tees, Esk and Wear Valleys NHS Foundation Trust, NHS Hartlepool and Stockton on Tees CCG, NHS South Tees CCG, Middlesbrough, Stockton, Hartlepool and Redcar and Cleveland Local Authorities and funding from the AHSN NENC.

The outcome of the project will be measured by evaluating the impact on reducing A&E attendances, reducing the numbers of inappropriate S136 detentions, monitoring re-attendance within 30 and 90 days and number of instances where resolution without deployment of emergency services is achieved.

Self-releasing Tourniquet

Project lead: Tony Wilson (North Tees and Hartlepool NHS Foundation Trust)

Typically a clinician places a tourniquet around the limb of a patient to induce swelling in the vein and provide a convenient site for venepuncture.  The tourniquet should be promptly removed immediately after the procedure, but this is reliant upon the memory of the clinician, with distractions potentially leading to the tourniquet being left in place for longer than it should be.  This can result in analytical error, discomfort or even injury, with incidents regularly recorded in the NHS.

North Tees and Hartlepool NHS Foundation Trust have collaborated with Vytek Ltd in the design of a self-releasing Tourniquet which automatically releases after a period of time.  The device, which can be re-usable or single use, improves the patient experience and improves the reproducibility of blood tests, as well as reducing the chances of discomfort and injury, providing a vital patient safety feature to this commonly used device.

The AHSN NENC and the Patient Safety Collaborative NENC have provided support both in terms of intellectual property registration and funding to support the manufacture and adoption of the pr