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

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

5. 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.

6. 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

7. 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)

8. 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’

9. Questions…..

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