Author: Vanesther Hamer

Alison Tavaré, GP and Primary Care Clinical Lead here at the West of England AHSN shares a personal experience of surviving sepsis, and explains why she’s now such a strong advocate for the use of the National Early Warning Score (NEWS) in supporting the identification of the deteriorating patient.

Surgery to stabilise my spine sorted the pain and power was restored to my leg. I was re-admitted feeling vaguely unwell and with a CRP of 600, but that had returned to normal and I arrived home, admittedly with a PICC line in place, but relishing the peace and the contrast to a busy Nightingale Ward.

A few hours later I was deeply asleep, but suddenly woke with a profound feeling of doom. My husband called 999 saying something had happened but I was not making sense. Within minutes an ambulance crew were running into our house and, blue lights flashing, I was transferred to hospital.

I remember doors swinging as the F1 ran onto the ward, but this was followed by a very disjointed conversation when I kept saying ‘I feel really, really ill’ and being told ‘you can’t have an infection as you have a low temperature and low white cell count’.

My bewildered and non-medical husband watched as his confident and experienced GP wife transformed into an anxious, timid patient whispering ‘you don’t have to have a raised temperature to be sick’.

I remember my heart felt as if it were about to explode, but seeing the cardiac trolley at the end of the bed and knowing the team would not have to go far when I arrested was an odd kind of comfort.

Again something changed; I became very calm as I knew death was imminent and resigned to the inevitable. There was a grey tunnel over my husband’s shoulder and as I gently moved towards it, I told my husband I was about to die but that I loved him, our sons, and my family. Apparently I started to look very pale, and luckily the F1 returned to the ward and put up some fluids; although I still felt very unwell the feeling of doom ebbed away. I spent hours in theatre having the pus washed out and the spinal scaffolding replaced.

Although sepsis was one of the diagnoses on my discharge summary very few people knew what had happened as any discussion provoked vivid and distressing flashbacks.

However, the following year, clinicians at my local trust were raising awareness of sepsis and I offered to share my experience. In preparation I reviewed my notes; there was mention of recent surgery and the PICC line, but as I suspected the provisional diagnosis was a panic attack. Seeing my severely ischaemic electrocardiogram and the evidence that my perception I had been in peri-arrest was correct made me cry. National Early Warning Scores (NEWS) had not been in use at that time but I noted the individual observations, which included both a marked tachycardia and tachypnoea.

My very private experience has now become much more public. I am involved in raising awareness of sepsis and improving the identification and management of the deteriorating patient. As part of this I learned about NEWS and with curiosity I looked again at my observations; my NEWS was 6, or 9 if the NEWS2 update was used and my confusion included. There is increasing evidence that the higher the NEWS on admission, the more likely the patient is to die.

So why does NEWS matter? As a GP I use NEWS alongside clinical judgement when arranging admissions, so supporting secondary care colleagues deciding where patients should be seen, by whom, and with what urgency. However, I feel strongly that NEWS also protects me as a clinician; if a patient unexpectedly has a high NEWS it makes me think ‘have I missed something?’ Sepsis and an overwhelming feeling of doom undoubtedly made me anxious, so the F1 did not intentionally make a mistake but instead the diagnosis was informed by my behaviour and not my physiology. If NEWS had been in place, a NEWS of 9 would have led to immediate escalation and it is unlikely I would have progressed to peri-arrest.

We all want to do the best for our patients, so think about spreading the NEWS and if it helps you sleep better at night what’s not to like?

Nathalie Delaney, Patient Safety Programme Manager at the West of England AHSN introduces ‘psychological safety’, how it impacts on teamwork and, in healthcare settings, how it impacts on patient safety.

When people talk about safety, it doesn’t take long for the topic of “safety culture” to come up. But what is safety culture? And why do people often want to develop it?

In the recent NHS Patient Safety Strategy, Dr Sonya Wallbank described the features of a safety culture. She set out the key ingredients as including psychological safety, valuing and respecting diversity, good leadership at all levels, a sense of teamwork, and openness and support for learning.

Of these, psychological safety is the most fundamental: it forms the building block of many of the other ingredients – respecting diversity, teamwork, and support for learning. It is similar to trust, but slightly different. Although lack of trust can be a cause of a dysfunctional team according to Lencioni, the two work hand in hand in creating strong safety cultures. When Google looked at what makes teams effective, they found that psychological safety was one of the crucial factors.

Image source: https://scienceforwork.com/blog/psychological-safety/

Amy Edmondson has done some fantastic research looking at “teaming”. Unlike stable teams who work closely together, often in healthcare we work in teams that are dynamic and formed for one task or another, even in multi-disciplinary cross-cultural teams. Edmondson gives the example of the Chile rescue where people came together from different professions, countries, even different nations; just like in the NHS.

Having psychological safety in the team can encourage people to speak up for safety – the theme of this year’s World Patient Safety Day.

Surprisingly, one of the things that can most inhibit psychological safety is incivility. And I’m not talking about Malcolm Tucker-level ranting. It can be the smaller, subtler aspects of incivility that can have an impact.

The character, Malcolm Tucker in the BBC show ‘The Thick of It’

The campaign, Civility Saves Lives has built up a wealth of evidence of the impact on rudeness on healthcare, and raising awareness of the negative impact that these behaviours can have on patient care. If you haven’t seen Chris Turner talk I would really recommend checking out his TEDxExeter talk, and the Civility Saves website.

So what can you do if you’re looking to build psychological safety in your team? For really practical advice, check out Google’s guide on Team Effectiveness, including questions on how to measure and foster psychological safety in the team.

Many of the behaviours that are discussed by this guide, and Edmondson, will be familiar if you read my earlier blog on what we look for when we are recruiting.

Curiosity, experimentation, listening, reflection; all these behaviours that can help you in your quality improvement activities can also help build psychological safety. It’s a win-win!

I’ve been really impressed with seeing teams participating in the safety culture work in the maternal and neonatal safety collaborative be able to constructively challenge each other, treat failures as an opportunity for learning, and learn together; embracing curiosity and vulnerability. Many of the teams are “working out loud” and sharing their learning on Twitter. Do follow #MatNeoQI to stay up to date with them.

At our last MatNeoQI learning event we used a liberating structure specifically designed to allow psychological safety in the room – known as 25/10 crowd sourcing which got everyone moving and sharing their ideas. Colleagues in other AHSNs have suggested this activity works better with some dance music or the flight of the bumblebee. Give it a go in your team and share with us how you get on.

So why should we care about psychological safety? There is clear evidence that it can improve healthcare for our patients and the teams we work in.

Kevin Hunter, Associate Director for Patient Safety & Programme Delivery at the West of England AHSN shares his experience, and learning, regarding speaking up for safety in a clinical setting. 

I’m sure many reading this have one or more examples of a situation where you wanted to speak up against the behaviours or actions of an individual or colleagues, but ultimately ended up remaining silent and perhaps later regretted your choice.

This could range from the extreme example of a colleague being reckless through their actions, to the not-so-easy-to-identify actions that border on bullying, perhaps ‘Managing by Fear’.

There have been a number of papers and articles written about empowering staff to speak up when concerned about the quality or safety of patient care, or indeed where displayed behaviours aren’t conducive to good communication; a ‘we’re all in this together’ type approach. Some studies have found that improving the safety culture links with improved patient outcomes, and you’d be hard pressed to argue against that.

However, it isn’t always easy and there may be a number of reasons why you felt unable to speak up at precisely the moment you should have; perhaps you didn’t feel empowered or confident, they were an expert in their field, they had positional authority and you were inexperienced or ‘lower ranked’ in comparison, or perhaps you just didn’t know how to start the conversation.

My training in speaking up for safety

During my career in the military we were taught from the start to challenge when we believe behaviours or actions of others are presenting or leading towards a dangerous situation. One example is on a firing range, which as you can guess is an inherently dangerous place to be when live rounds are flying around (hopefully towards the target!). Before each range session begins, you are collectively reminded of the safety expectations and if you see anything dangerous you are empowered to shout “STOP”; effectively bringing the exercise to an immediate halt.

Essentially everyone is empowered to act if they identify dangerous actions, be they accidental or by negligence, regardless of rank or positional authority. I therefore felt I was well equipped when I joined the NHS to challenge others if I felt the need to.

However, when the time arose to speak up I didn’t….

My first experience of speaking up for safety in a clinical setting

When starting one of my earlier roles within the NHS, I made sure I had a few days in theatres as part of my induction to observe different colleagues in their various roles. For the vast majority my experiences were fantastic, and I was in awe of the range of highly skilled services that my colleagues from across different specialities provided to our patients.

One afternoon I joined a theatre list alongside the theatre nurses. The consultant was clearly very experienced, made it clear they were in charge, and left people in no doubt as to that fact. There was also a junior trainee in theatre but it just felt a very different atmosphere to the others sessions I had observed. The trainee especially looked very nervous but I didn’t know why.

Whilst procedures (such as the WHO checklist) were followed, the trainee made a mistake with counting surgical swabs back to the scrub nurse. Whilst this is potentially serious, it was in fact a ‘near miss’, as there are backup systems in place to identify such mistakes.

However the ‘mistake’ led to the trainee being shouted at and demeaned in front of everyone and told to step back from the table. I left that operation feeling very uncomfortable with the atmosphere and intimidating actions I had witnessed.

Where I was stood meant I could see the two different swab numbers and what was happening, and the subsequent the treatment of a colleague; however on both occasions I didn’t speak up and quickly began to wonder why.

I arguably had positional authority (from my role), and deeply ingrained beliefs from my training that speaking up doesn’t just have to be when a dangerous event is occurring but also when unsure or indeed feel the actions of a colleague are inappropriate.

When speaking to some of the staff, I was told that this consultant is often like that in theatre. One of the colleagues saw the potential mistake looming and when I asked why didn’t they speak up at the time (bit hypocritical given I didn’t!) they told me they felt scared to interrupt as they would just be ‘shouted at’. Similarly to me, they suggested they would have spoken up if the backup system in place didn’t pick up the error, but in effect we collectively relied on the system to identify the mistake not our own ability to think and act.

My learning and advice to you

With hindsight, and now being much more knowledgeable in this topic, I know why I didn’t speak up. I was new to my role (‘is this how it works around here?’), I’d have been non-clinical challenging in a clinical setting, I didn’t want to embarrass a senior clinician, and indeed if I’m completely honest was probably a bit afraid. Perhaps because the incident had been avoided I had less reason to raise it, and assumed someone else would raise it if they were concerned.

Realising that whilst the immediate moment had passed, I decided to discuss my experience with the consultant and we went on to have a long honest conversation. I’m glad I did it, it wasn’t always an easy conversation, but they also didn’t realise their actions were having that effect, and assumed people would speak up. We both agreed to make some changes.

Whilst still wanting staff to recognise they were in charge during their list, the consultant agreed to work on empowering their staff and not to feel intimidated. If you’re reading this and are in a position of power; think about whether your words and actions really do empower your colleagues.

Finally, if you are reading this and are ever in a situation when you feel the need to speak up, please have the courage. I know I will next time….

Ellie Wetz, Programme Manager for the National PReCePT Programme, and West of England Medicines Safety Programme, shares how PReCePT has grown over the last five years.

In a world where the impact of our patient safety work may feel small, it is sometimes amazing and surprising to hear that a project you have worked on has been heard about, discussed and replicated on the other side of the planet.

I have the very good fortune of leading the national PREventing CErebral Palsy in PreTerm babies (PReCePT) Programme. When babies are born under 30 weeks’ gestation, they are at risk of developing cerebral palsy; by giving the mother magnesium sulphate (MgSO4) within 24 hours of delivery, this reduces that risk.

This programme was born in the West of England; a small acorn of a project at the time. It began in five maternity units in 2014/15, and saw the uptake of magnesium sulphate increase from 21% (before the project started) to 88% by the end of the project. This project resulted in seven cases of cerebral palsy being avoided, which had a significant impact on those babies and their families, and represents a lifetime health and social care cost saving of around £5.5 million. Not such a small acorn any more.

The success of the project made it ripe to be adopted and spread across the UK, and was selected as one of the seven national programmes to be delivered by the AHSN Network in 2018-2020; a seedling starts to grow.

By World Patient Safety Day 2019, the national PReCePT Programme will be active in 94% of maternity units across England; 3,373 mothers have been treated since the start of the programme; 91 cases of cerebral palsy have been avoided, and at least 19 of these are due to the PReCePT Programme. This equates to an additional saving of £15.2million in lifetime health and social care costs. From that acorn, an oak tree now grows.

The PReCePT Programme is incredibly lucky to be clinically led by one of the most inspiring, knowledgeable and respected neonatologists this country has to offer, Karen Luyt. She is the greatest advocate; spreading the word of our work regionally, nationally and internationally. In partnership with the West of England AHSN she submitted an application to the HSJ Patient Safety awards and PReCePT won the Maternity and Midwifery Services Initiative of the Year 2019. She has also had a paper on PReCePT published in the internationally acclaimed Vermont Oxford Network which has resulted in our PReCePT resources being downloaded in Wales, Scotland, and as far away as the USA and Libya.

From the seed of a project in the West of England, the branches of our oak are now wrapping around the world; supporting clinicians across the globe to help reduce the risk of cerebral palsy for potentially millions of families.

It has been such a privilege to work on this programme and be part of a national network of managers and clinicians all working to improve health outcomes for tiny, beautiful babies.

Read more, and watch our videos about the PReCePT project here.

Joanna Garrett, Senior Project Manager, shares her experience and knowledge of medication errors, and how her projects are working to reduce these in the West of England region.

I’m a healthcare professional and I’ve made a medication error.

Mine occurred late at night whilst working as a Paramedic. I was at the end of a long shift in a run of nights and I was fatigued. I was called, on my own, to a man in his mid-forties who had fallen at his home address in the early hours of the morning and broken his hip. He was screaming, his wife was shouting and confused (she’d just been woken up by his screaming) and getting a clear history was difficult. Perhaps you recognise some contributory human factors here which may have factored in the error I made.

Fortunately for me and my patient, mine was not a clinically significant error and no harm was caused. However, despite robust legislation and clear knowledge and understanding by healthcare professionals about the importance of accuracy, medication errors are still alarmingly common. Whilst it is thought that, like mine, in three out of four cases these are minor errors which are unlikely to cause harm, some errors can be catastrophic for patients.

In 2018 the Universities of Sheffield, Manchester and York estimated there were 237 million medication errors per year in the NHS in England, with 66 million of these considered potentially clinically significant errors. In 2017 the World Health Organisation articulated its third Global Patient Safety challenge of ‘medication without harm’ and aims to reduce severe avoidable medication related harm globally by 50% by 2020. Currently the estimated cost of managing definitely avoidable adverse drug reactions is £98.5 million per year and these errors are directly responsible for approximately 700 deaths annually. Reducing medication errors can clearly have a significant and immediate effect on patient safety.

Like me, every clinician has the potential of making a medication error and it is only by understanding the cause of medication errors that we can improve the processes to minimise the risk these occurring. The national Medicine Safety Programme (MSP) has been set up to work on reducing these errors and has three focus areas; high risk drugs, high risk processes, and patients with high risk vulnerabilities.

According to the 2018 report the most errors with potential to cause harm happen in primary care, as this is where most medication used in the NHS is prescribed and dispensed. The NHS long term plan indicates how useful pharmacists can be to improving medicines safety and this has already been proven in primary care. In 2012 the PRIMIS team found that the PINCER intervention was effective in reducing the range of clinically important and common medication errors in general practice, in combination with pharmacists undertaking patient reviews.

 

The quality improvement requirements in the new GP contract outline the expectations to improve prescribing safety in primary care, and the Academic Health Science Networks (AHSNs) are well placed to support this. During 2019-20 we are supporting the implementation of the PINCER intervention across England. This project supports multidisciplinary teams working in primary care to not only identify cases of hazardous prescribing, but also undertake root-cause analysis and quality improvement processes to reduce the likelihood of these errors re-occurring. This will ensure that medication errors are not only identified and corrected before harm occurs, but reduces that chance of the same error being repeated.

The health service still has a long way to go to removing avoidable errors but we are starting to see real change in this area. As a national project, PINCER collects anonymised data in one system and so far, the records of more than 10.7 million patients have been searched to identify instances of potentially hazardous prescribing. Over 500 pharmacists have undergone training to deliver the PINCER intervention and data has been uploaded from over 1,024 GP practices in England with more coming online every day.