NHS QUEST – NURSING AND MEDICAL STAFF ENGAGEMENT

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Presentation transcript:

NHS QUEST – NURSING AND MEDICAL STAFF ENGAGEMENT DR. PAUL PETER SR. PATRICIA BANNA-MARTIN NHS QUEST – NURSING AND MEDICAL STAFF ENGAGEMENT

Preventing Falls: Commit to action This gentleman is the Father of my colleague.

Learning is often founded on tragedy………… 64 year old patient was admitted on 02/11/07, initiated on insulin….Humalog Mix 25 ,10 BD Discharged at 2pm on 9/11/07 on Humalog 25 BD (F1) Visited by district nurse at 4.30pm… H Mx 25 , 25 given. Admitted on 10/11/07 into critical care And died…………………………………………….. (visited at 2130 by DN for a check BM) In June 2010, The National Patient Safety Agency (NPSA) issued guidance for all NHS organisations across England and Wales aimed at reducing the number of wrong dose incidents involving insulin. The Rapid Response Report, produced by the NPSA in conjunction with key stakeholders and NHS organisations across England and Wales, is as a response to 3,881 patient safety incidents reported between 2004 and 2009.

The Effect…. The family The nurses The doctors How did the family respond How did we feel – bereft, helpless, guilty – all of these. Confidence shattered

The Response Inter-professional Team Based Action Learning (ITAL) 3 day off-site training programme – commenced 2004 Multidisciplinary/ Scenarios based on real situations.. Education: Safe use of insulin module Creating the environment: Single insulin chart…Regional Insulin Safety and Knowledge(RISK) project Cultural changes: Transparency and honesty Proactive rather than reactive (involvement and reaction of those involved)

Finally……………… Why this case? I am here…. Honesty and transparency is key Support and education is crucial Zero tolerance to process but blameless to individuals….. Risk reduction is a continuous process……constant vigil and appraisal! I am here…. The F1 and district nurse But for the family….. All they said at the apology.. ….. ‘We understand, but please make sure it doesn’t happen to anyone else’

Questions…..

Developing a safety culture Make it real! Simulated multidisciplinary learning based on experiential scenarios – ITAL