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Sharing learning for a safer future

Bristol Patient Safety Conference 2019 @BristolPtSafety #BPSC2019

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Welcome Welcome to our sixth annual Bristol Patient Safety Conference. The aim of this event is to celebrate the great work currently being done to improve patient safety and patient care locally, regionally, and nationally and to facilitate the sharing of learning. We hope you enjoy our programme today made up of speakers and workshop leaders who are all experts in their fields and passionate supporters of quality improvement and patient safety. We are delighted to welcome Dr Arun Chidambaram, Deputy Medical Director, Mersey Care NHS Foundation Trust who will be talking about fostering a Just Culture at the Trust. We are also very fortunate to have Dr John Dean, Clinical Lead for Quality Improvement and Patient Safety at the Royal College of Physicians (RCP) speaking on A multi-professional approach to medication safety. Titles of the posters and names of their lead authors are in this programme. Our thanks to our distinguished judging panel: Panel Chair Miss Anne Pullyblank, Dr Lesley Jordan, Ms Anne Reader, Ms Jo Pendray, Ms Ann Remmers and Mr Kevin Hunter. Please take the opportunity to ask our competition entrants about their work and to share your own ideas with fellow delegates and speakers. We hope you will go away at the end of today with new patient safety and quality improvement ideas to implement in your own organisation, feedback on ideas you have shared, and with an understanding of what patient safety means in a range of different settings. We have been accredited to award 5 CPD points by the Royal College of Physicians (RCP) and you will be able to download your CPD certificate from our website after the event. If you would like to share items of interest on social media, our Twitter handle is @BristolPtSafety and the hashtag for the event is #BPSC2019. We hope you enjoy the day! Katherine Dougherty Organiser Bristol Patient Safety Conference

Programme 2019 8.30

Registration, tea and coffee, networking and posters


Welcome and introduction Mr Richard Annandale, Healthcare Lawyer


Opening Plenary: The psychology of improvement Anna Burhouse, QI Consultant, Director of Quality Development RUBIS.Qi

09.55 Delirium and its implications for patient safety Dr Claire Copeland, Clinical Director Ageing & Health, Forth Valley Royal Hospital 10.20 ImproveWell, empowering staff to communicate their ideas for improving care Peter Gray, Service Improvement Lead, and Zoe Nelson, Midwife Team Leader, Royal Cornwall Hospitals NHS Trust 10.40

Coffee and tea and posters


Workshop 1



13.00 The impact of the criminal law on healthcare Dr Jenny Vaughan, Consultant Neurologist, NW London Hospitals Trust 13.30 Building a Just Culture at Mersey Care NHSFT Dr Arun Chidambaram, Deputy Medical Director, Mersey Care NHS Foundation Trust 14.05 Workshop 2 14.50 Coffee and tea 15.10 A multi-professional approach to medication safety Dr John Dean, Clinical Director for quality improvement and patient safety, RCP 15.40 A QI project on reducing neonatal hypothermia, the challenges of sustaining improvement. Dr Clare Evans Junior Doctor 16.00 Poster competition prizes 16.15 Reflections on the conference Dr Tricia Woodhead, Associate Clinical Director for Patient Safety, WEAHSN 16.25 Final remarks Mr Richard Annandale 16.30 Close Workshops A Practical Tools to Support QI evaluation B Sharing learning on improving care for mothers and babies C Learning from suicide claims D Innovation in Healthcare E Managing concerns about individual performance



Plenary Speakers Anna Burhouse, Quality Improvement Consultant, Director of Quality Development RUBIS.Qi Visiting Senior Fellow University of Bath School of Management, Visiting Senior Fellow University of the West of England School of Healthcare, Consultant Child and Adolescent Psychotherapist 2gether NHS Foundation Trust, Severn Wye Recovery College Lead, 2gether NHS Foundation Trust. Anna is director of quality development at Northumbria Healthcare NHS Foundation Trust supporting NHS staff from across the UK to develop quality improvement and innovation capability and capacity, and to lead complex quality improvement work. Anna is a Health Foundation improvement fellow, an active member of the Q network and a member of the West of England Q Commons Stewardship Group. Dr Claire Copeland, Clinical Director Ageing & Health, Forth Valley Royal Hospital Claire is Clinical Director in Ageing and Health in Forth Valley Royal Hospital, Larbert, Scotland. She is a Fellow of the Royal College of Physicians and Surgeons Glasgow (RCPSG) and an Associate Fellow of the Higher Education Academy. Her sub speciality interests are stroke, delirium and medical education. Dr Copeland is the education lead for the Scottish Delirium Association and is faculty for the RCPSG ‘Managing Stroke’ and ‘Geriatrics for Juniors Connect’ symposiums in Glasgow. Peter Gray, Service Improvement Lead, Royal Cornwall Hospitals NHS Trust Pete is a registered Nurse with ten years’ experience predominantly in emergency medicine. He has worked in health informatics and currently works as a Service Improvement lead at the Royal Cornwall Hospital. Pete passionately believes that if the NHS is to improve its services and remain sustainable that frontline staff must have their ideas listened to and actioned where possible. Zoe Nelson, Midwifery Sister, Co-ordinator and Team Leader, Royal Cornwall Hospitals NHS Trust Zoe is currently Maternity Matron at the Royal Cornwall Hospital with over 24 years Midwifery experience. She is fiercely passionate about improving maternity services to meet the needs of the local community in rural Cornwall. She has worked with Pete Gray to pilot ImproveWell, the staff engagement App, which has now been rolled out across the Trust to support a robust Quality Improvement strategy. She has a special interest in supporting a sustainable workforce design, as well as the wellbeing of staff working within this challenging occupation. Dr Arun Chidambaram, Deputy Medical Director, Mersey Care NHS Foundation Trust Dr Chidambaram is a Forensic Psychiatrist and works in a community team (Forensic PD and ASD). He was appointed as Deputy Medical Director in Calderstones NHS Trust in October 2015 and in Mersey Care NHS Foundation Trust in August 2016. He is the medical lead for Centre for Perfect Care team (QI and R & D) for the Trust. He is a member of Strategic Partnership Board, overseeing the new care models in secure services in the northwest region. He is a member of Royal College Standard Setting Panel and an approved CASC examiner. He is a trained Case Investigator for Revalidation Support Team as well as NCAS. Dr John Dean, Clinical Director for quality improvement and patient safety Royal College of Physicians John has extensive experience in service redesign and quality improvement. He is Deputy Medical Director (Transformation) at East Lancashire Hospitals NHS Trust, where he works across the health economy leading service improvement. He is clinical lead for the Trust as a Future Hospital development site. He has been Divisional Director and Chief of Medicine at the Trust where he has worked since 2012, initially sharing the role of Associate Medical Director with Calderdale and Huddersfield NHS Foundation Trust.



Dr Jenny Vaughan, Consultant Neurologist, NW London Hospitals NHS Trust Jenny has been Consultant Neurologist for 14 years (NW London Hospitals NHS Trust and Imperial College Healthcare NHS trust). Jenny was the medical lead for the successful over-turning of the conviction of Surgeon Mr David Sellu for gross negligence manslaughter in 2013. Jenny has conducted surveys for the last three years in order to understand the impact of the criminal law on healthcare, especially after the conviction and erasure of Dr Hadiza Bawa-Garba. These surveys have informed law-makers, politicians, the media, the BMA, the royal colleges and the medical profession in general. She is currently assisting the Marx review into how manslaughter by gross negligence is applied to medical practice Dr Claire Evans, Junior Doctor A General Practice trainee in Exeter, Claire graduated from St. George's, University of London in 2012 going on to work in Paediatrics until 2017. Having an active interest in medical education and quality improvement, Claire has contributed to published research and has presented at conferences, both in the UK and abroad, winning the oral presentation award at the South West Quality and Safety Seminar 2018. She was a Peninsula Quality Improvement Fellow 2016-2017, implementing changes to successfully reduce rates of neonatal hypothermia. Claire was awarded a PG Cert, in Health Services Improvement from the University of Exeter in 2017.

Workshop Leaders Workshop A: Lou Hall, Programme Manager, South West Academic Health Science Network Louise is passionate about supporting people to best use evidence to support decision-making. She has worked in various research, evaluation and analytical roles across the health and care sector for over 10 years and now works for the South West Academic Health Science Network. Louise has developed measurement and reporting tools for practitioners, managed large scale, multi-site evaluations and supported practitioners and innovators to scope, plan and deliver evaluations in practice. Workshop B: Ann Remmers, Maternal and Neonatal Clinical Lead, WEAHSN Ann is also Clinical Director of the South West Maternity and Children’s Strategic Clinical Network. She has been involved in maternity and children’s health services for most of her career. Until July 2013 Ann was Clinical Director of Women’s and Children’s Health at North Bristol NHS Trust (NBT). Ann’s professional background is in nursing and midwifery. She has worked in both acute and community services and spent three years working in Australia. In 2007/2008 Ann was the clinical lead for the Darzi review of maternity and new-born services in the South West. Ann’s priority is patient safety across all health organisations and she is committed to improving outcomes and experiences and reducing variation in service provision across the South West. Natalie Delaney. Nathalie is an experienced operational manager and improvement facilitator with over ten years’ experience in the NHS. She worked first in acute commissioning and service improvement before moving to an operational role in a specialist cancer centre in 2009 ensuring delivery of cancer performance targets as well as working to ensure high standards of care for patients receiving cancer treatment. Nathalie joined the West of England AHSN in 2015.



Workshop C: Dr Alice Oates, South London and Maudsley NHS Foundation Trust (former Clinical Fellow, NHS Resolution) Alice graduated from the University of Sheffield with a medical degree and a BMedSci in 2011. After two years as a foundation doctor in Liverpool, she was successful in competing for an Academic Clinical Fellowship in General Adult Psychiatry within South London and Maudsley NHS Foundation Trust. During her fellowship she conducted research into decision making under stress in borderline personality disorder. Alice was working as a Clinical Fellow with NHS Resolution, this one year secondment was based within the Safety and Learning team and finished in September 2018. She worked with others across the health care system supporting a Mental Health project that examined and extrapolated the learning from inquests relating to suicides across England. The findings were published a national report this autumn to share the findings and learning from this work, the full report is available on https://resolution.nhs.uk/ resources/learning-from-suicide-related-claims/. Workshop D: Tricia Woodhead, Associate Clinical Director for Patient Safety, West of England AHSN Tricia has spent 24 years as a consultant radiologist in the NHS. During 12 of these years she was Medical Director and Director/ Quality and Patient Safety. She is a Health Foundation and IHI Quality Improvement Fellow and Improvement Advisor, having been awarded the Fellowship in 2010. Tricia is Associate Clinical Director for the West of England AHSN with a major responsibility for continuing the five-year South West Patient Safety and Quality Improvement Programme. She works across the South West, South of England and London on collaborative projects to improve reliability and patient safety in acute, community and mental health services. She is currently supporting the Royal College of Physicians as they develop their Quality Improvement Hub. Workshop E: Dr Sally Pearson, NHS Resolution. Sally graduated in Medicine from Leeds University in 1984 and became a consultant in public health medicine in 1992. She has over 20 years of Board level experience in the NHS as Director of Public Health in Gloucestershire Health Authority, and as Director of Clinical Strategy in Gloucestershire Hospitals NHSFT. She has successfully led strategic service changes covering most clinical areas. She has a proven track record in helping clinical teams reach consensus, creating a compelling case for change to support meaningful engagement with key stakeholders and the public. She now chairs the South West Clinical Senate, providing clinical advice to NHS England on all significant service change proposals in the South West of England. Ms Denise Chaffer, Director of Safety and Learning at NHS Resolution Denise is a registered nurse and midwife. She holds a Master’s degree in Management and Social Care, plus a Higher Education Teaching qualification and is currently in her final year studying for a PhD in Healthcare leadership. She is a professional Clinical Nursing leader with over 15 years’ executive experience, has been an Executive Director of Nursing in two Acute Trusts, as well as a Director in a PCT commissioning organisation. More recently she was Director of Nursing for North West London Area Team at NHS England as well as being lead for patient safety across the London Region. She has significant experience of working at international, national and regional level within acute and community settings, nursing, midwifery, education, and on major change and reconfiguration initiatives. She has recently published a book; ‘Effective Leadership, A Cure for the NHS?’ which draws on the personal experiences of a range senior healthcare leaders.



Poster Competition poster titles with author(s) 1

Improving Smoking Cessation Interventions on an Inpatient Cardiology Ward Dr Giles Atton, Cheltenham General Hospital

2 Significant Event Audit at Rainbows Hospice for Children and Young People Mrs Anne-Marie Murkett , Ms Tracy Ruthven, Rainbows Hospice for Children 3 It’s all fun and games until somebody gets hurt: teaching human factors to junior doctors Dr Lucy Baxter, South Tyneside District Hospital 4

Multidisciplinary simulation to influence widespread culture change in falls prevention Dr Lucy Baxter and colleagues, South Tyneside District Hospital


Optimising the management of Acute Kidney Injury at a District General Hospital Mr Callum Donaldson and colleagues, King’s College London


VTE Prophylaxis in Post-Operative Bowel Cancer Patients Dr Benjamin Walters & Dr Sophie Collins, Hampshire Hospitals NHSFT


Improving escalation and pre weekend documentation Dr Annie Wood, Dr Isobel Spring, Croydon Hospital


Improvements in sleep quality for hospital inpatients Dr Phillip Sparks and colleagues, Poole General Hospital


Huddle Up and Stay Safe Mrs Clara Grimes and colleagues, Weston Area Health Trust


Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Wristbands Dr Lydia Newton, Ms Ffion Dewi and colleagues, North Bristol NHS Trust


Use of a paediatric orthopaedic admission booklet to improve clerking documentation Dr Andrew Beverstock and colleagues, UH Bristol NHSFT


Improving Error Rate in Urine Fluid Samples Quality Improvement Project (QIP) Dr Jordan Cook, Dr Sarah Miller, Royal United Hospitals Bath


My Pregnancy @ NBT Dr Sonia Barnfield, Matthew Rees, Jodie da Rosa, North Bristol NHS Trust


Improving care of nursing home residents with dementia by implementation of new model for reviews Dr Jennifer Westwood, Dr Bethaney Mayhew and colleagues, Southampton General Hospital


A Sepsis Quality Improvement Project on an acute general medical ward in an inner city hospital Dr Kirsty Nweze and colleagues, Barts Health Trust


Improving Discussions about Escalation and DNACPR on Oncology Dr Joe Page, Dr Jason Chai, Dr Rebecca Squires, Dr Katherine Belfield, Dr Esther Hindley UH Bristol NHSFT.


Improving sepsis screening Nicola Lowe, Pippa Richards, Jenny Pickhaver, Sarah Ames, Taunton and Somerset NHSFT


Being SURE – The Patient List Redefined Dr Vinay Shah, Dr Robert Davidson, Dr Palbha Jain, Imperial Healthcare Trust



Poster Competition poster titles with lead author 19 Improving Care of Children Presenting to the Emergency Dept with Surgical Problems Dr Hao Meng Yip, Mr Max Denning, Dr Zhi-Yang Low, Dr Charlotte Clements 20 Audit of Autologous Stem Cell Transplant Pathway via Ambulatory Care Dr Hao Meng Yip, Dr Kwee Yong, Dr Dunnya De-Silva, 21

Optimising the medical weekend handover system at Weston General Hospital Dr Rachael Goddard & Dr Ann Archer et al Weston General Hospital


Reducing hospital-acquired heel pressure ulcers Ms Nicola Lowe, Karen Triggs, Caroline Upton, Jenny Pickhaver, Taunton and Somerset NHSFT


Improving antibiotic prescription documentation in a community district hospital Dr Natalia Sterling, Dr Nikheel PA Patel, University Hospital Southampton NHSFT


The Treatment is in the Details: How We Fail Patients with Pathology Forms Dr Michael Okocha and colleagues, North Bristol NHS Trust


Improving the safety of Phenytoin: Using Micro In situ Simulation Training Dr Emily Heathfield and colleagues, Ashford & St Peter’s NHSFT


From knowing to doing - Putting human factors to work for patient safety Ms Nicola Davey, Quality Improvement Clinic, Dr S. Lomax, Dr L. Chrisman, Dr Souman, Dr A. Kermode, Royal Surrey County Hospital


Don’t be a dipstick: reducing the use of urine dipsticks in diagnosing UTIs in the over 65s Dr Louise Poole and colleagues, Weston Area Health Trust


‘The antimicrobial journey’ Dr Annika Mills, Dr Andrew Follows, Dr Hannah Watson, Royal United Hospitals Bath


Vanquish Vancomycin Variation Dr James Pickard, Alysha Poole and colleagues, Weston Area Health Trust


On the benefits of celebrating learning from failure as well as “success”! Ms Benna Waites, Doris A. Behrens , Aneurin Bevan University Health Board


Can the number of sharps injuries in the Trust be reduced amongst clinical staff? Dr Oliver O’Sullivan, Dr Helena Edwards , Portsmouth Hospitals Trust


Application of a standardised measurement of Agitation Dr Thomas Salisbury and colleagues, Plymouth University Hospital Trust

33 Reducing the number of rejected samples at North Bristol Trust Dr Shuchit Soni, Dr Laura Powell, Dr Francesca Knapper, North Bristol NHS Trust 34 Improving care in sexual assault consultations Dr Elizabeth Mumby Royal Cornwall Hospitals NHS Trust 35 36

Project to reduce the time taken to update handover sheets by junior doctors Dr Simon Grant, Sue Bracey, University Hospitals Plymouth NHST


Reducing lithium toxicity in a general hospital Dr Philippa Lilford, Dr Rosalind Ward, Dr Katie Hall, Somerset Partnership NHSFT

Time to “Meet and Greet” Dr Rachael Chiumento, Jay Over and colleagues, Royal Cornwall Hospitals Trust



Poster Competition poster titles with lead author

38 Improving the Weekend Handover in a small DGH Dr Emily Firmston-Williams, Derriford Hospital, Plymouth, Dr Sally KoRoyal Devon and Exeter hospital 39

Improving prescribing safety in acute medical and surgical inpatients Dr Cameron Bullock, Dr Kate Hyde et al Royal Devon and Exeter NHSFT


Summaries given at the end of a Community Outpatient Clinic, assessment of Children with a Disability Dr Joanne Brooks, Dr Saba Hussain, UH Bristol NHSFT/Sirona Community care


Eye Care in ITU: Corneal Exposure Dr Ali Khanan Kaabneh, Derriford Hospital, Plymouth


Taking on the Patient Safety Hurdle in Enacting Change Dr David Peberdy Royal Devon and Exeter Hospital


“I’ve got a little list” - the scourge of a surgical junior Dr Hiba Khan, Dr Elizabeth Flesher, Dr James Marshman and colleagues Royal Devon and Exeter Hospital


Improving Safety and Emergency Care of Ward-Based Tracheostomy Patients Dr Peter Sykes and colleagues, North Bristol NHS Trust


Safe induction of Locum doctors Dr Fazia Muneer, Dr Maira Babar, North Devon District Hospital (NDDH)


Improving the documentation of ward rounds in colorectal surgery Dr Dominic Dewson, Dr Victoria Eves, Dr Robert Gaskell, Dr Alex Hardman, Emma Woodcock, Dr Ibrahim Akinpelu, University Hospitals Plymouth NHST

47 The new WHO checklist Dr Claire Cushley and colleagues, Gloucestershire NHS Trust 48 Your patient is deteriorating: It’s Time to ACT Dr Sara Blakeley and colleagues, Portsmouth Hospitals NHS Trust 49 Improving access to local guidelines for junior doctors using a mobile app Dr Jacob Adams, Dr Wai Huang Teng and colleagues, Yeovil District Hospital 50 Optimising Admission Temperatures of Preterm Infants to the Neonatal Intensive Care Unit Dr Jayne Sage, Dr Claire Rose, Southmead NICU, North Bristol NHST 51 Management of neonates born to mothers with Diabetes mellitus on insulin, admitted to NICU/ SCBU Dr Amruta Amit Fulmali, N Devon District Hospital, Barnstaple 52 QI cracking the code – What is a meaningful measure? Dr Matthew Ball , Dr J Ingham, Torbay and South Devon NHST 53 Fast track treatment - making impossible possible Mr Muhammad Faisal Khan, North Devon District Hospital (NDDH)



Vol 1, Issue 1

March 2019 Vol 1, Issue 1


for better, safer care

Quality Improvement: combining digital technology with innovative learning

> > > >

Learning from Deaths Patient Consent After Montgomery Refer-to-Pharmacy Criteria Led Discharge

> Winter is Coming > Shock through the heart, and you’re to blame > Caries Prevention


Patient Safety Journal is a record of the proceedings and learning shared at the Bristol Patient safety conference for more information visit: www.patientsafetyjournal.com



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Joopm Vol 1 Ed 6 (2017)  

The Journal has been created in recognition of the fact that not all information or advances in pain medicine can be presented in a randomis...

Joopm Vol 1 Ed 6 (2017)  

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