Improving safety for high-risk, deteriorating and vulnerable patients

Explore how patient safety is prioritised for key vulnerable patient groups

CPD Certificate of Attendance

Digital certificate - Included

Reed Courses Certificate of Completion

Digital certificate - Included

• A. Women’s Health: Maternity and birth Trauma 1:42:06

  • 1: Lessons from maternity investigations and tools to improve safety delivery 49:54
  • 2: National enquiries in maternity: what have we learnt and where are we going? 52:12

• B. Safety interventions for the deteriorating and high-risk patient 1:43:58

  • 3: Embedding an integrated approach to acute deterioration 52:24
  • 4: Embedding Martha’s Rule effectively in a deterioration setting 51:34

• C. Mental health in acute and community settings 1:31:48

  • 5: Mental health in acute and community settings – overcoming the challenges 49:38
  • 6: Reducing stranded patients in acute mental health wards: A year of learning 42:10

• D. Plenary Lectures 2:47:23

  • 7: Keynote from Dr Aidan Fowler, National Director of Patient Safety, NHS England 10:28
  • 8: Truly listening to patients: Embedding Martha’s Rule 26:46
  • 9: Creating safety every day in a 'degraded system' 41:49
  • 10: Keynote: Safe care, forever Groundhog Day. What's the reason? What's the answer? 53:21
  • 11: Practical safety strategies for today and tomorrow 34:59

This course includes a focus on three main patient safety topics:

A. WOMEN'S HEALTH: MATERNITY AND BIRTH TRAUMA

Lessons learned from maternity investigations and tools to improve safety delivery

• Interim lessons learned from Nottingham to deliver maternity improvement across providers
• Enabling greater collaboration between healthcare providers, healthcare professionals and other organisations to inform safer maternity care
• Improving training and engagement to underpin midwifery standards and working with key partners around unregulated practice
• A human factor training strategy to embed a systems-based approach: sustainably empowering frontline maternity staff to improve safety

National enquiries in maternity: what have we learnt and where are we going?

• Having a voice and being heard: addressing the long-term impacts of birth trauma and risks around health inequalities in maternity
• Unpicking key outcomes of the cross-party birth trauma inquiry and next steps

B. SAFETY INTERVENTIONS FOR THE DETERIORATING AND HIGH-RISK PATIENT

Recognising deterioration vs recognising dying: Embedding an integrated approach to acute deterioration

• Unpacking the risks of deterioration and putting a patient-centred plan together to respond appropriately
• DNACPR communications and what this means for care, with a focus on staff and community diversity
• Exploring the counterpoints of the assisted deaths debate – what exactly is assisted dying and what are the safeguarding challenges?

Martha's Rule and a bottom-up response – embedding Martha’s Rule effectively in a deterioration setting
Why to do it, how to do it?

• What exactly is Martha’s Rule?
• Exploring what has been achieved by forerunners to Martha’s Rule – lessons learned and overcoming the pitfalls
• Complexity of achieving cultural change to ensure the system achieves intended patient safety improvements from Martha’s Rule
• How can outreach teams be most effectively resourced to provide for Martha’s Rule?
• Identifying and overcoming unintended consequences of Martha’s Rule
• How to ensure that Martha’s Rule doesn’t increase health inequalities – risk factors, identifying deterioration and escalation
• Exploring the pitfalls and learnings of embedding paediatric parental concern as a forerunner to Martha’s Rule. What can adult services learn?

C. MENTAL HEALTH IN ACUTE AND COMMUNITY SETTINGS

Mental health in acute and community settings – overcoming the challenges to access and safety

• Using a systems approach to balance needs and safety across inpatient systems.
• The value of lived-experience in informing our understanding of needs and safety across inpatient systems.
• We will cover an HSSIB case study of the use of continuous observation with patients at risk of self-harm in acute trusts and the MINDS study, an NIHR-funded research project of discharge from in-patient mental health contexts

Reducing stranded and super stranded patients in acute mental health wards: 12 months of learning through engagement and data analysis

• Establishing a clinically led and operationally supported group to catalyse change
• The journey of developing a dashboard – live data
• Using SPC charts to measure performance and ongoing learning for areas of focus
• Seeking for a system approach and solutions to addressing delays and transfer of care

D. PLENARY LECTURES

Truly listening to patients: Embedding Martha’s Rule
10-minute interview with Merope Mills on her experience, what's been done and what she would like to see next

Creating safety every day in a 'degraded system'
This session explores the importance of listening to key voices in a system under pressure for effective policy, good data, mobilising action

• Is the system degraded or is it under pressure?
• Creating safety and safe care in services every day through and for: staff, patients and families, all working together to overcome core challenges
• What is going on at the frontline?
• The challenge of implementing safety actions when the system is under extreme pressure.
• Is current safety policy fit for purpose and what can we do to best address this?
• Understanding complexity and why it matters

Safe care, forever Groundhog Day. What's the reason? What's the answer?

• Clearing the ground
• What you already know/have known for a long time - Why things go wrong
• Inconvenient truths
• What to do

Practical safety strategies for today and tomorrow

• Effective intervention through a portfolio of customisable strategies: system interventions; risk control; improving the capacity to adapt, monitor and respond, and mitigation
• Splitting these strategies between improving overall quality and safety and managing risk
• Complementing these with short term safety strategies to manage pressures and rapid change through flexing resources, prioritisation and adaptive teamwork and leadership.
• Effective management of risk through a broad portfolio of both short and long-term strategies which can be customised to different problems and different contexts

This course is for:

• Patient Safety, Quality, Governance, Risk (Patient Safety, Quality, Governance, Lead Risk, Quality Improvement Head/ Leads / Manager / Specialists)
• Clinical Leaders and Teams (Medical Director, Clinical Director, Leaders and Teams of Maternity, Midwifery, Gynaecology, Neonatal, ICU, Emergency, Obstetrics, Anaesthesia, Surgery, Theatre, Chief Pharmacist, Mental Health, Learning Disabilities etc.)
• Nursing Leaders and Teams (CNOs, Nursing Directors, Ward Managers, Senior Staff Nurses, Sisters, Matrons and Midwifes. Specialist, community and practice nurses)
• Clinical Leaders and Teams (Medical and Clinical Director, Department leads, Chief pharmacists)

Explore how you can better improve safety for high-risk, deteriorating and vulnerable patient groups.

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