Patrick Keady

Patient safety research portfolio (psrp)




‘Without a national study, politicians and health professionals go into denial ….. we don’t have a problem’. This was one of the comments from Sir Liam Donaldson when he opened the Patient Safety Research Portfolio Conference this morning at the Royal College of Physicians

Speaking to a selection of the researchers that participated in the 36 patient safety research projects undertaken over seven years, at a cost of about 70p per NHS England employee per annum. He outlined his vision of the ten contributions that patient safety research offers to improving healthcare, as follows:


•    increasing awareness of patient safety – with clinicians, provider organisations and commissioners
•    understanding the causes of patient (un)safe-ty – and in relation to sleep deprivation, Sir Liam reminded us of the importance of the 48 hour week – clinicians are more likely to kill patients when they are tired.
•    more research in the young discipline of patient safety will enhance safety and improve productivity
•    establishing conceptual concepts – to enhance the ‘poverty of concepts in patient safety’
•    developing solutions – including improved design in healthcare, a recurring theme throughout the day
•    setting standards for information – before and after studies, randomised control trials etc
•    informing evidence based care
•    evaluating progress including checklists – twice as effective as education
•    nurturing researchers
•    and promoting leaders in patient safety


Professor Richard Lilford oversaw the Patient Safety Research Portfolio from its inception and this morning, he highlighted some of the successes of the programme. These included Professor Nick Barber’s discovery that nursing homes openly welcomed the prospect of his team observing medication errors and recommending improvements – their willingness could be related to the significant amount of time that care home staff spend in medication-related activities.


The day was chaired by Professor Paul Barach, one of the best Chairs that I’ve seen at a healthcare seminar/conference. He has has a very rare ability. He keeps the audience interested, even during the ‘graveyard shift’.  And he ensured that all 17 leaders in patient safety research, delivered their presentations in less than 4 hours. Now that is a rare achievement.


Citing an (unnamed) study elsewhere in the world, we heard that 9% of clinicians wash their hands before they touch a patient in the operating room and 17% do so after they touch the patient. Enter Professor Sheldon Stone summarising the successes of the Clean Your Hands campaign – and reminding us of the rationale for the campaign – 8% of patients acquire healthcare associated infections and their mortality is six times higher. Direct contact by hand is the main route of infection and Sheldon delivered this very serious message, in an entertaining way.


Chris Fuller described HHOT – the hand hygiene observation tool and Professor George Hanna told us about the checking procedures developed by his team for naso-gastric tubes. Dr Rebecca Lawton highlighted the success and lessons learned in evaluating non-luer spinal connectors.

While risk metrices represent risk and are almost universal in healthcare, Professor John Clarkson highlighted their limitations – they lack a systematic approach. And this is why he and his team are developing a toolbox for healthcare, that will include risk assessment models and tools and a process for escalating the higher risks.


Dr Karin Lowson’s insight into single hospital rooms, was topical and revealing. Patients in single rooms are more satisfied. They are less likely to acquire infection experience medication errors during their hospital stay. That said, some patient in single rooms are more likely to die and experience depression. And the risk of an adverse event and length of stay are about the same for patients in wards and in single rooms.

Much has been said about enhancing the patient safety agenda on the curricula of healthcare professionals. And recommendations as to this an be achieved, were provided by Dr Pauline Pearson and Professor Amanda Howe.


Professor Ian Watt gave an overview of how patients can ensire that clinicians deliver safe patient care – by making sure that the treatment is appropriate for them, that the treatment is as planned and in accordance with the appropriate protocol, and identifying how the health system can be made safer.


Dr Ken Catchpole shared his line of enquiry in operating theatres and elsewhere in healthcare. And he has four key questions. Is the healthcare team’s approach consistent with achieving high standards of care. Is what they are doing acceptable for Ken and his family. Does what the team are doing have to be like this. Is this the best it can be? Simple questions, revealing answers.


And Professor Mary Dixon-Woods outlined six rules for governance in operating theatres. The organisation is geared to promote patient safety. Protocols are deployed appropriately and everyone serves their spirit. Optimum communication. Minimal distraction and interruption. Effective authority and accountability. Reporting patient safety incidents.


Professor Justin Waring is in the process of summarising the outputs from the PSRP under the broad headings of the nature of patient safety, sources of risk and safety, and identifying the future direction for research.


And Martin Fletcher was the final speaker, talking about the science of safety. The NPSA Chief Executive sees the patient safety research agenda developing by networking the researchers, funding more PhD students and running another UK patient safety research conference.
Some of the many highlights for me were hearing about the science of safety, Ken Catchpole’s approach to enquiry in patient safety, how patients can be more assertive, updating the curricula, design of hospitals and non-luer spinal connectors, prospective analysis, competency based training in naso-gastric tubes and handwashing, observing hand hygiene, the benefits and weaknesses of focusing on improving culture and CHUMS.


With many thanks to Sir Liam Donaldson, Professor Lilford, the PSRP team and all of the researchers for making this fantastic conference a reality.


This entry was posted on 12/02/2009 at 07:11 pm and is filed under NHS, Safety, Patrick Keady, Public Health, Governance, Recommended, Personal Development, Health and, Patient, Legislation, Strategy. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response or trackback from your own site.


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