Learning and improvement updates

PSIRF update

Following the implementation of Patient Safety Incident Response Framework (PSIRF), Rapid Review has replaced 72 Hour Review learning meetings. Rapid Review meetings continue to provide quality assurance to ensure timely and accurate decision making in the reporting and review of patient safety incidents to promote a positive patient safety culture.

Decision making in Rapid Review focuses on learning and quality improvement initiatives.

With the implementation of PSIRF from 1 July 2023, the Trust will be taking a different approach to its management of patient safety incident responses. A key principle of PSIRF is to take a considered and proportional response to patient safety incidents. There are a number of system-based approaches that can be adopted to learn and improve as a result of a patient safety incident.

‘Harm Free Care’ is a collective approach we use for our patient safety initiatives aimed at making sure patients are kept safe and free from harm in our care. We have active and productive groups established with clear work plans, fully supported by our clinical teams. In line with PSIRF principles existing quality improvement plans will be mapped against learning identified in patient safety incidents to promote the implementation of PSIRF principles.

If you would like to get involved in any of the Harm Free Care groups please contact Governance and Quality Team.

Radar Update

Amputations on MCFT caseloads

Any amputations that occur in service users on an MCFT caseload should be escalated via Radar and undergo a Rapid Review. As amputation is considered moderate plus harm and therefore reaches threshold for Rapid Review. A Radar report should be completed by the clinical service that first becomes aware that an amputation has be undertaken.

It is accepted that amputations can occur due to aetiology, health of service user etc. Rapid Review meetings provide quality assurance to ensure timely and accurate decision making in the reporting and review of patient safety incidents to promote a positive patient safety culture by identifying any potential learning and also celebrating good practice.

Service Development

Paediatric Pressure Ulcer and Wound Care

There is an established workstream to develop resources to support clinical staff in relation to paediatric pressure and wound care delivery. This includes:

• Development of an e-Learning education awareness package
• Development of a Paediatric Wound Care Formulary
• Engagement with Alder Hey Childrens Hospital and the Childrens Community Nursing Service to share best practice in relation to pressure ulcer and wound management.

Tissue Viability Nurse Group

Tissue Viability Link Nurse Group has been created to enhance the knowledge and skills of community nurses in all aspects of wound management, in line with national and local guidelines. The Link Nurse Education Programme will contain specific learning objectives relevant to clinical practice and through enhanced skills gained, will support their teams and the tissue viability service.

The aim of the group is to ensure that each area has access to a qualified nurse who can act as a resource within the realms of tissue viability, to ensure that information and support is cascaded to all teams as well as providing an arena for education and reflected practice that is firmly based on practical requirements. The Link Nurse Group will consist of a Health Care Professional from each District Nursing team, this will enhance collaboration between teams thus improving continuity and ultimately improve patient care.

Anyone who has a special interest in Tissue viability and believes they meet the criteria (must have all wound competencies and have attended all wound care training) are encouraged to inform their team leader.

The PSIRF replaces the Serious Incident Framework (2015) and makes no distinction between ‘patient safety incidents’ and ‘Serious Incidents’. Instead, the PSIRF promotes a proportionate approach to responding to patient safety incidents by ensuring resources allocated to learning are balanced with those needed to deliver improvement.

PSIRF replaced the use of the Serious Incident framework within Mersey Care from 1 July 2023. Any patient safety incident learning responses conducted under PSIRF will allow us to make sure that learning and improvement identified is sustainable.

Patient safety incidents are unintended or unexpected events (including omissions) in healthcare that could have or did harm one or more patients.

Rapid Review Outcomes

The effective management of incidents is an integral part of the way the Trust meets its duty to minimise the risk to its patients and staff, with the aim of maintaining their health and safety. Following the implementation of PSIRF, Rapid Review has replaced 72 Hour Review learning meetings. Rapid Review meetings continue to provide quality assurance to ensure timely and accurate decision making in the reporting and review of patient safety incidents to promote a positive patient safety culture.

The RAG rating (Red Amber Green) outcomes following the review of moderate + harm incidents have now been replaced in line with PSIRF principles. Decision making in Rapid Review focuses on learning and quality improvement initiatives alongside identified local and national priorities.  

Further details on the Rapid Review outcomes can be found below, any queries in relation to this please contact the Governance and Quality team.  

1. Incident meets national reporting requirement or national priority for escalation as Patient Safety Learning Review (PSLR) – Refer to Trust Patient Safety Panel

National priority to be referred for review by another agency e.g., ‘for referral to local authority Safeguarding’.

National priority incident requiring local PSLR e.g. ‘Never Event’.

2. Incident meets local priority for escalation as PSLR – Refer to Trust Patient Safety Panel

Local priority incident requiring local PSLR e.g., ‘deterioration in health of an inpatient requiring admission to a general hospital’.

3. Incident may meet criteria for ad-hoc PSLR – Refer to Trust Patient Safety Panel

Emergent patient safety risk or incident with learning and improvement potential possibly requiring ad-hoc local PSLR e.g., ‘contributory factors not well understood, minimal improvement activity underway’ or ‘unexpected incident not accounted for in PSIRF’.

4. Incident meets Patient Safety Review (PSR) criteria – To be managed by Place / Monitored via Divisional Safety Panel

Learning and improvement to be captured by PSR. One of the following PSIRF toolkit items to be used:

• After Action Review
• Immediate Collective
• MDT Review
• Debrief
• Horizon Scanning
• Team Based Learning Event
• Thematic Review.

5. Incident may be approved with local response – Incident closure / no further review or escalation.

Incident not for further review, give rationale: e.g., incident type and contributory factors well understood and reflected in improvement work.

Patient Safety Team

There is a PSIRF tool kit selector  which can be used to support decision making in relation to selection of an appropriate PSIRF learning response.

Further PSIRF guidance and resources can be found on YourSpace.

Radar update

Catheter Associated Urine Infections

CAUTI should be recorded in RADAR as moderate + harm. Please see screen shot below of how to record CAUTI on RADAR.

Delay in lower leg assessments

Any lower leg assessment that is not completed within two weeks of wound development (in line with NICE guidance) is to be reported via Radar. Screen shot of categories to be selected can be found below.

Deterioration of lower leg wounds

Any deterioration in lower leg wounds to be reported in Radar. Screen shots of categories to be selected can be found below.

Promoting and supporting our staff in delivering safe administration of insulin in the Community Care Division.

Welcome to your learning and improvement updates for August 2023. This month is devoted to providing you with feedback from the recent staff questionnaire relating to caring for patients who are prescribed insulin.

In recent months, there has been several patient safety incidents relating to the administration of insulin to our patients in the community, both in their own homes and within care homes. The effective management of incidents is an integral part of the way the Trust meets its duty to minimise the risk to its patients and staff, with the aim of maintaining their health and safety.

A staff questionnaire was developed in the hope we could get views and any suggestions for improved safety culture around insulin administration and diabetes management. We wanted to better understand the specific challenges you have so we can help to improve safety in the community settings. We also need to understand how we can better prepare you, in terms of providing the appropriate level of education and skills so you can be both competent and confident when caring for your patients living with diabetes.

We will aim to give full and detailed feedback to each of the places in relation to the survey results but please see below for a provisional divisional summary which is helping us inform our quality improvement plan.

Feedback from insulin staff survey

The staff survey results identified the following themes:

• Insufficient time allocated to complete insulin visits safely. This was due to multiple reasons e.g. complexity of patients, including patients prescribed more than one insulin and unstable patients requiring further action and attention, management of diabetic emergencies (including access to device to check ketones), care homes access issues - which often take more time than single occupancy dwellings, needing further time to complete administration of insulin and complete documentation, impact of volume of timed visits and timely access to GP/specialist diabetes support
• Impact of late or no referrals for insulin administration including safe / timely allocation, delay / missed insulin administration, communication challenges with GP, diabetes service, secondary care (i.e., when last received insulin, changes to prescription during admission), increased risk of prescription / authorisation to administer errors, sometimes no education provided by wards (patients with potential to be self-caring), lack of information to deliver safe care and poor discharge
• Challenges in relation to access to care home/multi-patient occupancy dwellings due to issues such as access to front door, key code number, medication room and clinical documentation, car parking availability, availability of care staff to support with identifying patient (including knowledge of carers in relation to residents and clinical significance of insulin), availability of reception staff to answer intercom, volume of insulins allocated (especially weekend), time of visits coincide with care home medication rounds and protected meal times, use of agency staff by care homes and language barriers with care staff
• Confidence in relation to patient identification within care home/multi-patient occupancy dwellings, impacted by quick turnover of patients with intermediate care settings, availability / reliance on care staff to confirm patient identity if not familiar or patient lacks capacity, photograph on patient room not always updated, agency care staff not always familiar with residents and language barrier, limited / non-English speaking care staff
• Challenges in relation to completion of clinical documentation related to connectivity of electronic patient record (EMIS / RiO) and functionality of EMIS mobile contributing to documentation being completed post visit, access to electronic patient record to confirm outcome of previous visit, completion of correct EMIS clinical template, development of specific RiO insulin administration template, IT/ lap top issues (including battery, mobile connection, overheating, switching off), incorrect labelling / visibility of uploaded documents to EMIS Web, insulin authorisation to administer not on MCFT paperwork to support safe care delivery, time consuming to collate capillary blood glucose readings on RiO (if requested by diabetes specialist nurse). It was noted there was a mixed response in relation to staff preferred format of documentation i.e., electronic versus paper with positives and negatives aligned to each method and references made to the ‘blue book’ being reinstated
• The survey explored staff competence drawing up insulin from 10ml vial and results highlighted issues in relation to availability of safety needles, limited / no experience of undertaking this clinical task and a significant training deficit identified
• Challenges if relation to access to specialist advice were identified and included no service provision out of hours / weekends, accessibility / communication with specialist diabetes service, delay in review / response, difficulties contacting acute Trust or GP, availability of a prescriber in the diabetes team, ability to check ketones.

Staff were asked for any suggestions at all how we can improve our safety culture around insulin administration and diabetes management – your responses were really valuable and included:

Thank you

We want to thank all the teams that took the time to complete the staff survey which has helped us to better understand the specific challenges you have so we can help to improve safety in the community settings.

We also need to understand how we can better prepare you, in terms of providing the appropriate level of education and skills so you can be both competent and confident when caring for your patients living with diabetes. There is now an established Insulin Harm Free Group with a clear work plan, which is fully supported by our clinical teams. If you would like to get involved with this group please email the Quality and Governance team.

Finally, can we summarise all the learning so far we have gained from our insulin patient safety incidents and results of our insulin staff survey – can this be shared across all teams please.

Learning from insulin patient safety incidents and results of our insulin staff survey

Time - teams have been asked to re-assess all insulin patients for planned insulin administration and if patients are complex – to reallocate them at least a 30 minute timed visit. This communication has gone out via all safety huddles. Please let us know if you have not received it. However, we appreciate that some events will be unplanned and for that we advise please don’t worry, take your time, act always calmly and safely and if you cannot leave the patient – escalate to your team leader/nurse in charge. Please do not rush as we know that this is when you are most likely to make a mistake. Take care of the patient and take care of you too!

Vials - Please can we ask if you have any referrals for insulin administration that is required to be drawn from vials to contact the referrer to establish if an alternative insulin can be prescribed that can be administered via a pen safe device.

Care homes / multi occupancy dwellings – Engagement with local authority care home partners has been undertaken to highlight challenges to care delivery including a more focused approach in identified hot spots. Work with medicines management undertaken to enhance safety in care homes, labelling has been agreed by Boots for individual pen devices and sourcing boxes with lids attached to use in care homes for storage.

Safe delegation – delegation of insulin to non-registered staff is being explored, two District Nurse teams have been identified to complete training and identify suitable patients. If successfully embedded we will increase scope and scale to standardise this offer across the division.

Patient identification – A team leader in Liverpool Place is leading on a workstream to support communication and patient identification of service users in care homes, taking the learning from community mental health teams.

Clinical documentation - Gap analysis in relation to clinical record keeping processes across the wider division to optimise templates on EMIS/RiO has been completed. Codes added to EMIS to monitor demand and schedules. Task and finish group commenced to support documentation standards.

Specialist advice and staff training - Work has commenced via place with Diabetes Specialist Teams to support patient reviews & optimise insulin regimes. Wider system engagement to discuss current Diabetes specialist provision and access across the Trust and how we reduce the gaps is ongoing. Improved training / education and competency programme for all staff administering insulin / diabetes care has been scoped. Work with Trust Preceptorship team to support confidence and competence in our preceptors with regards to insulin administration and diabetes. Furthermore, a review of current policies / SOPs is being undertaken to support learning and improvement work.

Health Education England e-learning package: Safe administration of insulin

The safe administration of insulin e-learning package can now be accessed via ESR. All staff involved in the administration of insulin are required to complete this package. Feedback from clinical staff who have completed the training includes the session takes approx. 45 minutes to complete, and staff have found the training beneficial for their clinical practice. You will receive a certificate of completion which can then be used as evidence for revalidation!