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Patient centred safety 

The newly published NHS Patient Safety Strategy has been described by the NHS Confederation as a "paradigm shift" in the way the NHS treats patient safety.  A key feature is a move away from a culture of blame to one of learning.

This paper from Ninewells hospital in Dundee shows what a safety learning culture looks like in practice.  Better still, it explores - and resolves - a safety issue by using patient experience as a key learning tool.

The hospital's Radiology Department, in common with units across the UK, uses Magnetic Resonance Imaging (MRI) for diagnostic tests.  MRI scanners are generally safe - but they generate magnetic forces that can be up to 30,000 times the strength of the Earth's magnetic field.  These forces can cause overheating and malfunction in implants such as pacemakers and artificial valves. 

Safety is addressed via a system which requires referrers (GPs, hospital doctors and others such as physiotherapists) to ask patients to list any implants or foreign bodies they have.  A secondary check by radiography staff immediately prior to the scan provides a safety back-up.  But, say the authors, "Despite constant efforts, there have been recurrent incidences of safety breaches with patients attending MRI department with implants, including pacemakers, when none have been declared".

Rather than ask referrers what was going wrong, the radiographers went to the patients.  A questionnaire survey asked patients what safety checks they had undergone at the time of referral.  It found that almost regardless of the type of referrer (GP etc) only 50-55% had been asked about pacemakers, and fewer than 50% had been asked about valves, clips and other metal objects in the body.

In case patients had misunderstood or forgotten their conversations with referrers, a second survey was carried out, using face to face interviews to check and clarify patients' responses.  It found similar results.

Rather than blame the referrers for compromising patient safety, the radiographers developed a "strategy for change", with risk alerts, and reworking of questions on the referral form.  In the twelve months following, there was no incident of any undeclared implant.  This, say the authors, "was in sharp contrast to the continuous stream of significant events earlier that had prompted our intervention in the first instance".

The safety exercise was carried out at a Scottish hospital.  But "pathways for MR referral and acceptance are broadly similar throughout the UK [therefore] this survey could be usefully applied to provide further insight to other NHS centres on MRI safety issues".

You can download the report via our website.
Safety evidence on tap
There is plenty of other evidence on how safety can be achieved in hospital settings - and how patients can help.
This case study looks at a patient-led safety survey in an English hospital, where outcomes included increased communication awareness and more open sharing of results.
This ethnographic research describes how to be a very safe maternity unit.  A key feature is "collective competence" across consultants, midwives, maternity care assistants, porters etc.  This was based on social relationships, learning together, and understanding  each others' roles.
The NHS Patient Safety Strategy sets out a new approach to safety, under the themes of insight, involvement and improvement. 
For more on patient safety, search "safety" here:  
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