One of PSL’s ambitions is to help health care as a system put safety as its core purpose rather than just “one priority of many”.  One of its guiding principles is that patient involvement is essential – not only at the point of care but also contributing to analyses when things go wrong and helping to design improved systems.

Although only three years old, Patient Safety Learning has already established thriving communities of practice and has run some very successful initiatives including a campaign to improve outpatient hysteroscopy services and a scheme to support staff involved in serious incidents.

More than 20 percent of women who undergo outpatient hysteroscopy experience significant pain. Stories from hundreds of women have now been captured on the Hub and feedback from people all over the globe shows that they are using the material to find “what good practice looks like”, says Ms Hughes.

Being involved in unsafe care can be deeply traumatising for healthcare professionals – and some people never work again after an incident where a patient was harmed. PSL has worked with experts to define good practice in this area and to ensure that staff are treated with courtesy, dignity and support.

During the coronavirus pandemic PSL took the opportunity to consolidate some of its work and develop a major policy report called A Blueprint for Action that builds on thinking and research over the past 15 to 20 years. This was followed this year by  Mind the implementation gap: The persistence of avoidable harm in the NHS  that tackles that issue of turning knowledge and recommendations into improved systems.

“We should be providing healthcare professionals with the environment that enables them to do their job safely and to provide safe care for their patients and families – and we’re not doing that as well as we ought to, says Ms Hughes.

Helen Hughes has held leadership roles in healthcare in the UK and the WHO, the National Patient Safety Agency, Equality and Human Rights Commission, Parliamentary Health Services Ombudsman and the Charity Commission. Helen’s previous leadership roles in patient safety include, Director of Operations of the National Patient Safety Agency and executive lead of the global ‘Patients for Patient Safety’ programme at the WHO.

Patient Safety Learning’s the hub is an award-winning platform to share learning for patient safety. It offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety concerns and how to address them. Membership is free – you can register at www.pslhub.org.

Read and watch the full series on our website or on YouTube.

Early in the coronavirus pandemic Patient Safety Learning recognised that staff safety was also a patient safety issue. For example, staff who could not access appropriate personal protective equipment (PPE) were putting themselves at risk and therefore potentially also putting patients at risk. “This was reflected in World Patient Safety Day last year – that patient safety and staff safety are really two sides of the same coin [and] we need to stop thinking them as entirely separate things”, says Ms Hughes.

In fact, the organisation used the time when people were unable to get out and about to develop a major policy report called A Blueprint for Action that builds on thinking and research over the past 15 to 20 years. Ms Hughes says: “We were trying to answer the question, “If we know what we know now, compared to 20 years ago, and … the system is responding by taking more action, why have we still got the same level of harm? Why is harm so persistent?” So, we built on the knowledge in A Blueprint for Action and one of the initiatives … that we called for was the development of patient safety standards for organisations”.  A useful analogy is the fire safety strategy that every Trust will have. This is basically a policy framework that sets out “what ‘good’ looks like”. The organisation’s performance can then be reviewed and monitored against the standards to make sure that the policy has been implemented in an effective way.  “You don’t have to have any of that for patient safety – there isn’t that framework”, says Ms Hughes.

Ms Hughes also draws attention to the recent World Health Organization report entitled, Implications of the Covid-19 pandemic for patient safety: a rapid review, to which she contributed.  “It’s a WHO rapid review on covid-19 and patient safety – the implications – and I would encourage people who are interested in this field to pick up and learn from that”, she says.

The Patient Safety Learning Hub has recently celebrated its two-year anniversary but there is still more work to be done.

Mind the Implementation Gap

A recent report called Mind the implementation gap: The persistence of avoidable harm in the NHS deals with addressing the ‘no do gap’.  There is now a mass of knowledge about the causal factors of unsafe care, including investigations, inquiries, coroners’ reports, the work of the Healthcare Safety Investigation Branch and a plethora of insight testimonies from patients and families. “Let’s start applying that knowledge for improvement. Let’s take that knowledge and act on it. So, we don’t want to see more inquiries into maternity care that has failed mothers, families [and] babies. We want the recommendations from those reports and from those inquiries be implemented”, says Ms Hughes.

The report identified the need for a monitoring or oversight body in the UK that follows up recommendations, operating as a safety management system. The problem is that “we’re not we’re not designing our system as a learning system. We’re not acting on our insight and then evaluating what works and then sharing that knowledge. So, let’s turn it into a more effective learning system”, she says. Part of PSL’s role will be to try to influence through policy, working with parliamentarians and accountability frameworks, working with national bodies and also working with organisations on the ground to help them assess what more they need to do and help them put plans in place to deliver that, she adds.

Healthcare professionals

“We should be providing healthcare professionals with the environment that enables them to do their job safely and to provide safe care for their patients and families – and we’re not doing that as well as we ought to. We know from the scale of avoidable harm [that] more needs to be done so I think I think it’s almost a recognition that we need to transform ourselves to be able to provide people with the environment to do the right thing more readily”, says Ms Hughes. It is not only a matter of learning from situations when things go wrong but also sharing good practice. “There are lots of examples of where people are doing rather well [and] we need to share”, she says. Healthcare professionals are almost all interested in patient safety and need to understand how they can contribute further by sharing their experience. If they feel they’re in a supportive environment then it could be useful to raise their concerns, suggest improvements and create networks to work with colleagues. “The most effective way of improving safety is to work as an effective multi-disciplinary team – there is no doubt about it”, she says.

Helen Hughes has held leadership roles in healthcare in the UK and the WHO, the National Patient Safety Agency, Equality and Human Rights Commission, Parliamentary Health Services Ombudsman and the Charity Commission. Helen’s previous leadership roles in patient safety include, Director of Operations of the National Patient Safety Agency and executive lead of the global ‘Patients for Patient Safety’ programme at the WHO.

Patient Safety Learning’s the hub is an award-winning platform to share learning for patient safety. It offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety concerns and how to address them. Membership is free – you can register at www.pslhub.org.

Read and watch the full series on our website or on YouTube.

PSL has now been in existence for just over three years and so designing the Hub has been an important milestone. “Hearing from people that are using the knowledge they find on there, engaging in communities of practice, sharing their experience and then applying it for improvement – that’s the main impact – the fact that we can actually support people deliver change and improvement”, says Ms Hughes.

Two examples of success stories illustrate the achievements of the PSLH; one is staff-related and the other is patient-related:

Claire Cox, a patient safety manager at King’s Healthcare, and a couple of other colleagues created a network of people working in patient safety. “They wanted to engage with others to share their experiences, to ask for help, to invite experts in, to create a community of interest [or] community of practice.  In the year that we’ve been supporting them through the Hub and through various other means they’ve grown to be over 620 members”, explains Ms Hughes.  A weekly ‘drop-in’ session has been established and this regularly attracts large numbers of participants. A recent meeting had over 140 participants. Sometimes external experts are invited when group members have identified the need for specialist input. Already there is “a plethora of examples of how people are learning and improving what they do around patient safety in their organisations”, she adds.

The Hub is also used to share knowledge about risk and about good services. An example here outpatient hysteroscopy services. More than 20 percent of women who undergo outpatient hysteroscopy experience significant pain. “That level of pain is quite shocking – the services that that are private provided by some organizations do not meet Royal College guidelines”, says Ms Hughes.  The patient groups involved have been sharing their experiences and telling their stories. “We use the Hub to help capture those stories and those experiences so people can use that to inform, engage and influence…….. There are hundreds of women’s personal experiences on there. We’ve had those pages viewed over 99,000 times now from around the globe and we are getting feedback that people are pleased that they’re able to source what good practice looks like and they can make sure in their own care that they are getting the services that they should be”, she explains.

Second victims

“‘Second victim’ is a term that was first coined many years ago by a colleague of mine, Professor Albert Wu, in the [United] States and I think even he now says maybe that’s not the best phrase to use. …… but what he was doing was highlighting an inadequacy ….. in recognizing how traumatising being involved in unsafe care can be for staff members”, says Ms Hughes.

Health care professionals are usually committed, dedicated individuals who sometimes find themselves in situations where a series of system errors culminate in patient harm.  “People that have been involved in serious safety incidents, you know, have been so traumatised some people will never work again – some people carry the guilt with them for years”, she says.

She recalls working with a very senior consultant who carried in the inside pocket of his jacket a list of all the patients who had been severely harmed or had died under his care. He said, “I never want to forget them but I never want to forget how I failed them so that I continue to improve”. Despite the obvious guilt and pain, this was a positive response to serious safety incidents.  “What we’ve been doing with many experts in this field is bringing together really what is good practice – how should staff be supported at the time where there may be an incident that is very severe. How are people comforted?  How are people helped to get home safely  …. that they’re not put into a car and driving on a motorway when they’ve had something really traumatic happened. [And then] when there is undoubtedly the necessity for a review or an inquiry they’re being treated with courtesy, with dignity, with support – they’re not being vilified, they’re not being blamed. They are being encouraged to give their opinion of what went on – that insight informs understanding of the causal factors. ….. Staff are encouraged to contribute to any understanding but they’re supported in terms of their own personal and psychological health and well-being”, says Ms Hughes.

Helen Hughes has held leadership roles in healthcare in the UK and the WHO, the National Patient Safety Agency, Equality and Human Rights Commission, Parliamentary Health Services Ombudsman and the Charity Commission. Helen’s previous leadership roles in patient safety include, Director of Operations of the National Patient Safety Agency and executive lead of the global ‘Patients for Patient Safety’ programme at the WHO.

Patient Safety Learning’s the hub is an award-winning platform to share learning for patient safety. It offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety concerns and how to address them. Membership is free – you can register at www.pslhub.org.

Read and watch the full series on our website or on YouTube.

Patient Safety Learning is a charity that works as an independent voice for system-wide change through policy influencing, campaigning and promoting ‘how to’ resources for patient safety Improvement, explains Ms Hughes. The Patient Safety Learning Hub (PSLH) was established to provide free, easily-accessible information about patient safety for everyone. “By everyone we mean literally everyone – so it was designed by and for clinicians, patient safety experts, patients, family members, policy makers, academics – everyone. So, we wanted a knowledge repository, all in one place, that people could find easily and use to inform their campaigning, their work, their education”, she says.

In 2021 the PSLH won the Leading Healthcare Award for the patient safety category and it is now a finalist for another award. Being an award winner gives greater visibility and credibility to the organisation’s work “so it helps with our sharing and our marketing of what we do”, says Ms Hughes.

The PSLH was born of the idea that that “knowledge knows no boundaries – everyone should share for safety”. Even the World Health Organisation (WHO) was thinking about how it could create a global knowledge platform. Ms Hughes explains, “I think it’s not a unique idea – what is unique is the realisation of it. As of last week, we’ve had our millionth page view so in the three years that we’ve developed it …… we’ve got sufficient content on it and engagement with various communities for people to come back and find it valuable. So, what’s unique about us is that we took the ideas and we share the ideas of the Hub and build on that.”

In fact the Hub has now had a million page views from people in more than 200 countries. Although it was started as a UK-based resource, over time more and more people have found out about it and user numbers have grown.  There are more than 450,000 unique users that have been using this from around the globe.

Patient safety as a core purpose

One of PSL’s ambitions is to help health care as a system put safety as its core purpose. Ms Hughes says:

“We are very mindful that patient safety and indeed staff safety is often one priority of many and actually we feel it should be a core purpose and it should be designed as such. So, if you look at other industries, they have concepts of ‘Safety Management Systems’ where the whole industry comes together – whether you’re a service provider, whether you’re a regulator, whether you’re a customer and – everyone is very clear what the safety requirements are what the safety standards are and how safety will be delivered. Healthcare as an industry, both in the UK and globally, is just not in that place yet.”

Patient involvement

“Patient involvement in patient safety is absolutely essential and not because it’s the kind and nice thing to do but because it works”, explains Ms Hughes. Research evidence and personal testimonies clearly demonstrate that engaging patients and their families makes care safer.

Patient engagement is needed at three levels. First, at the point of care, when decisions are being made about procedures, about sharing information and about deciding whether to consent for treatment. “The patient safety component of those decisions and that engagement between clinicians and patients and families is essential”, she says.  The second level is if things go wrong. “In the UK [there are] 11,000 avoidable deaths each year [due to] unsafe care”, notes Ms Hughes. “If things go wrong it’s important for patients and families to have that knowledge, to have that shared ….. but also, to help understand what went wrong and why. And the patient and family perspective can be quite unique”, she says. The patient and family can see the whole care pathway whereas clinicians tend to see only a component part of it. The third level is in designing new systems and improvements. If things have gone wrong engaging users of the service – patients and families – to help redesign a service enables the organisation to learn from the wisdom of patients and families and make sure that the service meets their needs, she adds.

Helen Hughes has held leadership roles in healthcare in the UK and the WHO, the National Patient Safety Agency, Equality and Human Rights Commission, Parliamentary Health Services Ombudsman and the Charity Commission. Helen’s previous leadership roles in patient safety include, Director of Operations of the National Patient Safety Agency and executive lead of the global ‘Patients for Patient Safety’ programme at the WHO.

Patient Safety Learning’s the hub is an award-winning platform to share learning for patient safety. It offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety concerns and how to address them. Membership is free – you can register at www.pslhub.org.

Read and watch the full series on our website or on YouTube.