1. Welcome Patient Safety Matters Sussex Partnership
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Co-brand logo here
Welcome
Patient Safety Matters
Sussex Partnership

2. Situation
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CQC 2016 report ‘The Trust should ensure that learning of incidents is effectively shared with staff.’
Report & Learn Bulletin averaged 80 downloads a month.
Feedback from frontline staff was that they didn’t know what the learning was from SIs across the Trust.
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3. Background
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Serious Incident Framework Supporting learning to prevent recurrence
NHS Improvement – ‘Recording incidents protects patients from harm and saves lives’
SPFT Incident, Serious Incidents and Learning from Deaths Policy – ‘It is very important that we learn from incidents and serious incidents and ensure we use this learning to improve the care we provide.
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4. Welcome Benefits to others
Learning from SIs and incidents shared widely with staff at all levels.
Service Users receive safer care from better informed staff.
Reduced risk of recurrence of incidents trustwide.
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5. Driver Diagram
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6. Welcome PDSA Testing Ramps for content of PSM A P S D
Engagement of different experts for content of PSM
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Cycle 1D: Working with clinicians requesting PSM on Serious Incident in their area of expertise
Cycle 1C: Pharmacist Lead engaged to write PSM for medication error
Cycle 1B: Co-production with carer made patient’s story more engaging and final draft read through for sense check by Jenny (receptionist)
Cycle 1A: First draft - feedback from clinical team -too corporate in language

7. Welcome Measurement Barriers to measuring quantitively.
No baseline data as previous report was very different and only uploaded to Trust intranet and is the quantity of bulletins sent out a measure of improvement in learning?
This was not the only change idea that was implemented at the time to share learning from incidents.
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8. Welcome Measurement However qualitative feedback has been great!
‘Well written, clear learning points – and these are specific enough for us to relate them to our own cases. I think it is very accessible in this format. I have circulated for LD team meetings.’
‘During the core service inspections the staff fedback that these were very useful in helping them to look at their work and approach to situations, and make workable changes to improve the safety and experience of patients’ CQC Report Jan 2018.
Copies are now ed to BSUH, Eastbourne General Hospital, Nurse Education after requests.
Shamelessly stolen by Cornwall and others.
Copies are shared and discussed with patients in at least two of our hospitals – with one hospital hosting a ‘Patient Safety Matters’ group for service users.
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9. Welcome Recommendations
Involve as many people from different backgrounds (patients, carers and staff) at the start of the project as you can.
Develop your measurement plan.
Find your Jenny!
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10. Welcome Key improvement message Main title for slide set
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