1. Patient Safety in Mental Health Wednesday 1 st April 2015 Chris Stanbury, Director of Nursing and Governance

2. What do we mean by ‘patient safety’? Embedding a learning culture in the organisation that promotes minimising harmful events and reducing the chance of re-occurrence of harmful events. Implementing systems and processes to identify and manage potential for harm, risks of harm occurring and monitoring harms that do occur – always focussing on co-production and learning lessons. Ensuring staff have the passion, knowledge, confidence and skills to eliminate/minimise patient harm and maximise patient safety.

3. Harms in mental health Tangible harms such as falls, physical health deterioration, health care incidents, health care acquired infections, medication adverse effects and neglect. Harms associated with mental health such as suicide, para-suicide and self harm. Harms to others such as verbal and physical aggression, abuse, assault, violence and homicide. Harder to define harms such as exploitation, vulnerability, loss of dignity/freedom/liberty/control/hope and/or self determination, trauma and psychological injury.

4. Safety incident management systems Individual clinical risk management Engagement and observation Minimising harm and promoting safety Learning culture Learning lessons improvements Environmental risk management Co-production and collaboration

5. Patient Safety in TEWV NHS FT TEWV Culture Quality Strategy Patient Safety Framework Corporate Safety Incident Team Improvement projects and programmes Recovery Strategy Trustwide Clinical Risk Management

6. Patient Safety improvements Board sign up and commitment Culture of continuous improvement –Kaizen Staff engagement Recovery and co-production User feedback Estate design Incident reporting systems Incident management systems: review and analysis

7. Patient Safety Project Work LIPS –violence reduction Falls Pathway Learning Lessons Positive Behavioural Support Physical Health Care Suicide Prevention Force Reduction Risk Management Safe Staffing