Putting safety first

Luke Blair
By Luke Blair     17/02/2023

We’re all familiar with complaints, whether making or receiving them. Mostly, it’s about irritating but mundane stuff like parcels and deliveries.

But now imagine a complaint about life and death. Imagine it comes from a bereaved partner, son or daughter. Then imagine it is your job not only to hear that complaint, but do something about it – and try to ensure it never happens again.

That formidable role is carried out every day of the week in the NHS by patient safety teams or, to give them their proper titles, quality improvement and patient safety teams. As you might imagine, in a hospital of any size this is a significant, and valuable, job.

So for each directorate in this particular organisation, there is just such a team. And today I am speaking to the team in the cardiovascular directorate.

“We are actually the advocate for the patient in any complaint involving a safety incident,” says the team’s manager. “Have we answered their questions? Have we fixed their issues?”

And if that sounds hard, it is – for both sides. The patients and their relatives themselves find it difficult to say anything when surrounded by staff who are, clearly, doing their very best but may simply be too busy or stressed to provide exactly what is needed.

For example, the manager says: “In one case her partner had just died in our care and she wanted someone to talk to. She didn’t think of herself as a ‘complainer’ but she just wanted that face-to-face contact. For us to explain what had happened. She wanted a human face.”

The head of safety and her team write to every single family of any relative who has died in hospital under the Directorate’s care. They also receive, on average, around ten ‘incidents’ each day to review. These are not only deaths but anything which might be considered to have ‘gone wrong’ in any way – from the wrong bedlinen to the wrong food.

Avoiding a ‘blame culture’ is thus another aspect for this multi-faceted, multi-skilled team.

“If there’s been an error, it’s usually a wrong process, but people can take it very personally. So we have to ask are we providing enough support to staff, as well as patients. Have we given them enough to do their job properly?”

Patients of course can be a liability to themselves. Among the most common incidents that need to be investigated are medicines administered in the wrong way, and falls.

“We had a patient who used to go to the shop to buy their newspaper every morning, wheeling an intravenous drip with them on a stand. Then one day, they decided to take the stairs…”

Fortunately, the patient recovered well from the resulting fall and head injury. As a direct result of this incident, stricter instructions to patients about their safety were issued.

And this goes to the heart of why the team’s work is so valuable. For every incident, however minor or major, the resulting learnings can create lasting benefit, for everyone.

A deaf patient admitted during COVID was upset that she could not see people’s mouths and read their lips and complained. We’d been unable to provide language support on the ward. So we introduced transparent face masks instead. It was so simple and yet no one had thought of it.”

Then there are the medicines that patients used to bring in themselves and leave behind in random places. Now, lockable bedside cabinets are provided. Or the multiple phone numbers and email addresses patients used to be given for the complaints department. Now there is just one, for all such calls or emails.

Each of these was a problem solved with a simple idea – even if the process involved several teams working in a multi-disciplinary way – and, of course, these were the relatively straightforward ones. Others are much more complex and need the involvement of many dozens of people, from all over the hospital.

Some of these are difficult to manage, to see where change has to be made. And it seems that no matter how many improvements are made, no matter how quality has improved, the issues and complaints continue to come in, at the same pace as before.

Who would willingly work in such a complex, endlessly challenged team? “I love my job,” says the manager’s colleague. “No day is the same.”

They enjoy making – and seeing – real impact when the small, clever changes and ideas are implemented.

“A number of incidents involving blood supplies led to an investigation and one of the outcomes was the idea of a ‘Lesson of the Week’ based on any trends we see from what’s coming into the team – sort of short sound bites for immediate sharing of learning from an incident. This has been really successful so we’re rolling it out to other teams.”

“We can change a process or make a small suggestion that means doing something different and taking just a few seconds to do so, can save so much time later on.”

No wonder the team have the words ‘quality’ and ‘improvement’ in their name. Indeed, working with the Quality Improvement team across other sites – such as at the Royal Brompton – is also an important part of what this team does.

I suggest they are like the “oil in the machine’ – getting the hospital to run ever more smoothly and cleanly, ironing out the bumps and grit along the way.

The manager seems pleased with this metaphor but gently indicates that time is up. She has another busy inbox full of the latest issues and incidents to work through. It seems that no matter how much oil you use, there will always be some grit.