Priority One - Patient safety


PriorityWhy we have chosen this priorityWhat we are trying to improveWhat success will look like
Embedding the Learning from Deaths programme. To improve the quality of care delivered to service users, both when things go well and when things could have been done differently. The use of reviewing real cases to learning from and improve care delivery. A robust review process in place to ensure improvements in the delivery of care and a reduction in harm to patients.
Complete the development of and start to embed the Patient Safety Incident Response Framework into the organisation. To further improve our ability to learn from incidents, utilising a new methodology. Implement principles of the Patient Safety Incident Framework into the organisation.As per the Learning from Deaths priority, this has been delayed due to the ongoing pandemic. All aspects of our service, including the care delivered to our service users, our ability to respond quickly, as well as corporate functions. The Trust's ability to be able to deliver serious incident investigations under the new framework. Reduction of current trends of incidents. 
Ensure that appropriate, safe decision making is applied for patients who are left at home following assessment and treatment. Although work commenced on this priority in 2021/22, this will be continued in 2022/23 to ensure that safe discharges on scene are implemented for patients who are not conveyed to hospital following assessment and treatment by our staff. A reduction in the number of reported incidents and occurrence of negative patient feedback for patients who are not transported to hospital.  Embedding of the 'non-conveyance' monthly audit to review appropriateness of clinicians' decisions to leave patients at home.A reduction in conveyance and an improved patient experience and outcome.
Learning from incidents and patient experience to improve the safety and quality of care patients receive. Although robust systems are in place for both safety and feedback, we have identified that there is a need to connect the two to provide a greater impact. Lessons are learned and fully embedded within the organisation to improve the safety of delivery of care and an improved patient experience. Fully joined up learning from the triangulation of data from both patient safety incidents and patient experience through feedback.
How we will monitor progress:

Monthly Board reports detailing Learning from Deaths data and through the Patient Safety and Experience Group with progress reported bi-monthly to the Quality Governance Committee.
Responsible lead:
Melissa Dowdeswell, Director of Nursing, Quality and Improvement
Date of completion:31 March 2023

Next Page: Priority Two - Clinical Effectiveness

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