Safety For All Conference Report

On Wednesday 7 December 2022 the inaugural Safety for All conference was held at the Royal College of Physicians in London. This event brought together a wide range of attendees all with a shared interest in calling for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all.

The full report can be accessed here and an executive summary found below:

Morning keynote addresses

The Conference opened with three keynote addresses.

John Dean, Clinical Vice President at the Royal College of Physicians (RCP) set out the importance of patient safety in their activities. He highlighted the RCP’s work to improve the transition of care between hospital and home, including developing a toolkit on safe medicine at discharge and an associated patient health guide and checklist. He also spoke about their work carrying out independent service reviews, providing a source of independent advice and support to healthcare organizations. 

Henrietta Hughes, Patient Safety Commissioner for England, spoke about the challenges we face in improving patient safety, including the need for effective engagement and responses to patient concerns and ensuring that staff feel psychologically safe to speak up about safety incidents. She also went on to speak about having seen, in her initial weeks in her new role, many pockets of good practice and efforts being made to put the patient voice first.

Patricia Marquis, Director for the Royal College of Nursing (RCN), spoke about the extremely challenging healthcare environment nursing staff are currently working within and the need for a long-term approach to workforce recruitment and retention. She also reflected on the recent decision by nurses to take industrial action and the steps being taken to ensure patient safety is maintained throughout this period.

Hearing the patient voice

The first panel session at the Conference focused on the importance of engaging with patients and families at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. Some key reflections in this discussion included:

• Patients and family members are a key source of insights and knowledge when undertaking a patient safety investigation, involving them is not only the right thing to do but also crucial to learning.
• Language can often act as a problem for engaging with patients, with too many acronyms and healthcare jargon presenting a significant communication barrier.
• Importance of supporting patients, not just giving them the opportunity to ask questions but the knowledge and tools to know what questions to ask.

Extravasation

In a presentation, Andrew Barton, Chair of the National Infusion and Vascular Access Society, spoke about the risks posed by extravasation injuries. These injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue causing trauma. He set out the scale of this patient safety issue in the NHS and the need to improve reporting and learning from these incidents to prevent avoidable harm.

Improving staff safety

The second panel discussion of the day focused on the importance of ensuring the health, safety and wellbeing of staff across the healthcare system and the benefits that this has for patient outcomes and developing a safety culture. Some key reflections in this discussion included:

• Workplace safety standards and processes must be accompanied by strong leadership and management, underpinned by shared ambition to support this from national agencies, governments and regulators.
• Safety challenges in moving to a new hospital building/re-designing existing spaces, considering examples from Liverpool University Hospitals NHS Foundation Trust.

Afternoon keynote address

Lesley Kay, Deputy Medical Director at the Healthcare Safety Investigation Branch (HSIB), gave the afternoon keynote address to the Conference reflecting on the role of HSIB and its forthcoming organisational transformation into two new bodies in April 2023, the Health Services Safety Investigations Body and the Maternity and Newborn Safety Investigations Special Health Authority. She spoke about some of their recent investigations and their education programme, which to date has had four and a half thousand learners.

Creating a safe environment in hospital theatres

In a presentation, Lisa Nealen, Peri-operative Practitioner at Gateshead Health NHS Foundation Trust, set out the hazards posed by surgical smoke. She outlined the safety risks for staff, current legislation concerning this and spoke about the introduction of smoke evacuation products to reduce the risk of harm.

Persistence of avoidable harm

The third panel discussion was focused on the persistence of avoidable harm in healthcare and the action needed to tackle the implementation gap that exists between what we know improves patient safety and what is done in practice. Some key reflections from the discussion included:

• Problem of incident investigations focusing on guidance being followed correctly and if this is not the case simply prescribing additional training, rather than considering the ‘work-as-done’ reasons why this may not have been implemented.
• Question of whether we are effectively implementing learning from public inquiries, given the monitoring of report recommendations is patchy and evaluation of their effectiveness is unclear.

Preventing workplace stress

The final panel session of the day considered workplace stress, how to prevent and link between this and patient safety. Some key reflections included:

• Highlight various sources of guidance and support available from organisations such as the RCN and NHS Employers.
• The example of the Safety Incident Supporting Our Staff (SISOS) initiative at Chase Farm Hospital in supporting staff involved in patient safety incidents.