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

Any amputations that occur in service users who have been on an Mersey Care Foundation Trust caseload up to six months prior to amputation should be escalated via Radar. A Radar report should be completed by the clinical service that has first contact with service user post amputation.

A risk stratification tool has been developed to support decision making in relation to amputations. If any potential delays in care / treatment are identified in line with PSIRF local priority, and to promote a positive patient safety culture the incident will be scheduled for discussion in Rapid Review and the most appropriate clinical team will be requested to complete the paperwork and attend Rapid Review.

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.