1. Patient Safety and Learning from Incidents

2. Claire Bennett
Moving and Handling Lead/Advisor
Verity Boord and Anna Henshaw
Clinical Advisory Team
Tracey McKenzie
Head of Compliance

3. Case Study 1 - Ward
You are working on a community hospital ward and have been asked to hoist a patient from chair to a commode. As the patient did not have a sling, you went to the store cupboard and selected one from the shelves that looked the right size. Your colleague is unsure how to connect the sling to the hoist, so working it through together, you found a solution that looked right and proceeded to hoist the patient. During the transfer, you noticed that the patient leant heavily to one side, and whilst still in transfer, the patient suddenly slipped through and hit the floor. On assessment you find that the patient has sustained a serious head injury and requires medical attention, although the patient has not lost consciousness.

4. Incident Details
Details:
I Witnessed fall. Patient had a guided fall from an overhead hoist and unfortunately hit her head on the floor and sustained a laceration on the right side of her head. Patient was hoisted from chair intending to put her on the commode as she needed toilet, while she was up on the hoist the chair was moved away and we were about to put commode in place, patient leaned to her right side and the hoist tipped to the side causing patient to be hanging almost halfway out of the sling and we supported her to the floor unfortunately her head hit the floor as it all happened too fast. No LOC, pt remained alert and orientated.
Type:
Cause:
Fall From Height - Patient
Site:
Community Hospital
Department:
Ward One
Directorate:
Actual Impact:
5 Catastrophic / Death

5. Undertake Audit - Refer for SIRI
Action Type:
Undertake Audit - Refer for SIRI
Issues Addressed:
Was the correct equipment available for staff to use.
Action Description:
Audit and review of Moving and Handling Equipment and Handling Aids
Action Taken: (Progress)
The Audit highlighted insufficient equipment on the ward with low stock levels of slings and glide sheets. It also identified that some staff felt they lacked awareness re using the hoist and needed further training. The Moving and Handling Advisor undertook some training with the therapy staff re advanced complex handling techniques and has a meeting arranged to discuss remodelling and standardising the moving and handling equipment on the ward.
Owner:
Claire Bennett
Responsibility Of:

6. Learning Outcomes
Staff will ensure that a moving and handling plan is in place is in date and read, understood prior to commencing manual handling support to patients.
All staff to read Moving and Handling Policy SH HS05 and Bariatric Handling Policy SH HS12. The importance of following Trust Policy to be discussed at 1:1's /team meetings.
Staff will ensure hoists are checked visually by staff weekly and this is documented.
Staff will ensure slings are checked visually by staff weekly and this is documented.
Whilst staff had completed patient handling training they may have needed further hoist training. It is the responsibility of the staff member to ensure that they have both the skills and competency and to identify any further training needs or support Safe Moving/Patient Handling.
Learning outcomes and recommendations will be shared with both Adult Services and the Patients and their representatives.
Some of the Learning outcomes following this investigation will be shared with the staff team and wider organisation if related to working practises to ensure that these types of incidents do not reoccur.

7. Case Study 2 - Community
Telephone call received from an OT with the following information: OT’s have been asked to see a patient urgently, as carers are hurting their backs during moving and handling tasks. Plus size patient, had taken to her bed in the last week and was refusing to cooperate with the care staff to get out of bed. Pressure areas were also reported, and the Patient had possibly suffered stroke in the last week, had been seen by GP, no further investigations were actioned. Normal level of function was step around transfer with assistance of 2. No other aids had been required. OT had requested support from Manual Handling Advisor, who after discussion then contacted clinical advisory team to also attend to complete a joint visit. OT had also requested district nurses to attend to check and advise around potential pressure areas.

8. Response
Joint visit completed with Patient, Carers, Community OT, SHFT Manual Handling Advisor, Clinical Advisory Therapists, District Nurse.
Discovered immediately that there were no pressure concerns reported by patient or carers, so District Nurse left.
Patient consented to moving in the bed with OT and clinical advisory therapists and moved well, so agreed to try and sit on the edge of the bed.
Patient was anxious and fearful of falling off the bed. It was clear that she required a lot of verbal reassurance and positive reinforcement.
The patient needed a period of therapeutic input, to increase her confidence in her own physical ability and to advise the care staff in the correct manual handling to promote her independence.
The team left the carers with a set of slide sheets, after demonstration how to reposition the patient safely in bed.
OT made a urgent referral onto her Community Physio colleagues to request assistance to prevent long-term change in function.

9. Incident and Near Miss Reporting
An incident is something which has caused or may cause unnecessary harm. Reporting incidents and assessing risk is a vital part of the Trust's processes for improving safety and quality. 
Incidents should be reporting using Ulysses Safeguard, our online reporting system.

10. Contact us
If you have a query about an incident, please contact us:
Tel: /4087
Meet the team
Kay Wilkinson - SIRI and Incident Team Manager
Tel:
Mandy Rogers - SIRI and Incident Officer
Tel:
Lee Rockingham - SIRI and Incident Officer
Tel:  
Daniel Green - SIRI and Incident Administrator
Sam Clarke - SIRI and Incident Administrator

11. Contact Us clairebennett2@nhs.net v.boord@nhs.net Tracey McKenzie
Head of Compliance, Assurance & Quality
If you have a query about an incident, please contact us:
Tel: /4087
Kay Wilkinson - SIRI and Incident Team Manager
Tel:
Mandy Rogers - SIRI and Incident Officer
Tel:
Lee Rockingham - SIRI and Incident Officer
Tel:  
Daniel Green - SIRI and Incident Administrator
Sam Clarke - SIRI and Incident Administrator
Claire Bennett
Moving & Handling Lead/Advisor
Verity Boord
- AHP Clinical Advisor / Physiotherapist