We are delighted and excited to share some of the great work that has been taking place across Wessex to support the WHO World Patient Safety Day. The objectives of World Patient Safety Day are to increase public awareness and engagement, enhance global understanding, and spur global solidarity and action to promote patient safety.

1. World Patient Safety Day
17 September 2020
Celebration of achievements

2. A note from the Patient Safety
team, Wessex AHSN….
It is always important to highlight successes and triumphs in
Patient Safety where there is so much work going on every day to
be celebrated and shouted from the rooftops.
On World Patient Safety Day 2020 it is more important than ever
during what has been such a difficult year to take a moment to
pause and reflect on just some of the wonderful projects and the
individuals and teams who have worked so tirelessly during this
time.
Whilst we can’t be there with you in person today, on behalf of
Wessex AHSN we would like to offer our heartfelt thanks to each
and every one of you for helping to improve care for our patients.

3. To celebrate World Patient Safety Day we asked for examples of great
practice so that we could recognise individual and teams’ successes across
Wessex. Input was received from:
Fareham and Gosport and South Eastern Hampshire CCGs
Hampshire Hospitals NHS Foundation Trust
Southern Health NHS Foundation Trust x2
Portsmouth University Hospital x3
The Royal Bournemouth and Christchurch NHS Foundation Trust
Bournemouth University
Wessex AHSN
University Hospitals Southampton

4. Set up and establishment of a care home
collaborative
The work was undertaken by South Eastern Hampshire / Fareham and Gosport CCGs
quality team to support the set up and establishment of a care home collaborative for
our geographical footprint.
The Quality Collaborative (QC) was developed following a multi-agency appreciative
inquiry workshop where it was recognised that health and social care partners
supporting residential, nursing homes and domiciliary providers could work together
more effectively. The aim of the QC is to develop joint strategic action plans in response
to themes and trends identified locally, using intelligence gathered through multiple
sources to inform a proactive, preventative approach to quality improvement. Themes
identified in the first six months included: end of life care, activities and well-being, care
planning and risk assessments as well as medication management, with joint action
plans being developed to respond to each of these areas. The Care Homes Forum was
revised to reflect these trends and feedback was exceptionally positive ‘It was the best
forum we have ever had… we learnt so much and have implemented changes in the
home since, including a breakfast club, which the residents love!’. Other feedback has
included that the support of the QC has enabled the ‘highest CQC inspection in years’’
for one provider, with partners stating that the QC ‘inspired positivity’ and has ‘changed
the way [staff] will work collaboratively’. During Covid-19, the QC commenced daily
meetings to deliver a supportive function for independent providers, reviewing
intelligence daily and working with services of need as required. The QC also evolved to
include primary care, with attendance at ward rounds and check-ins focusing on the key
themes for quality improvement.
Suzanne van Hoek – Deputy Director of Nursing and Quality,
Fareham & Gosport and South Eastern Hampshire CCG

5. Critical Care Academy, COVID Staffing Hub, Staff Testing, Falls
Awareness & Weekly Ward Staffing Report (COVID and beyond)
Louise said…The Senior Leadership Team at Hampshire Hospitals NHS Foundation Trust would like to thank
all of our staff for their continued commitment to patient safety over the last 12 months with particular focus
on the earlier part of 2020 which has tested us all. Their strength, resilience and adaptability has meant that
we have been able to continue to deliver high standards of care.
Critical Care Academy: following on from the COVID surge we recognised that we did not have enough
nurses trained to care for patients in the ICU. We developed a two week high intensity educational
programme focussing on key elements of care for ICU patients followed by a rotation that ensures each
nurse works on ICU monthly to keep their skills up. We now have a cohort of ready-to-go nurses who are
confident in caring for ventilated patients. ICU multi-disciplinary team, Helen Neary Divisional Chief Nurse for
Surgery, Mel Price Service Manager for Critical Care, Hayley Blandford, Vicky Taylor, Jo Stokes & Hayley
Churcher Clinical Matrons, Lucy O’Bierne Lead Educator for Critical Care COVID Staffing Hub.
As COVID took hold and staff needed to be rapidly redeployed we introduced a Matron of the
Day (MoD) model which had Clinical Matron cover 24 hours a day, responsible for nurse staffing
allocation across each site. The MoD ran operations from a central hub which became the point
of contact for all things nurse staffing. This allowed a global view with a senior decision maker
who could ensure Safer Staffing principles were met and that wards were adequately resourced
through the COVID surge. Katie Prichard-Thomas Associate Director of Nursing, Clinical Matrons
and the entire nursing workforce.
Weekly Ward Staffing Report (COVID and beyond) Some of the Matrons took a different
approach to planning and predicting safe staffing using a site based model supported under the
Staffing Hub with the Matron of the Day. This considered total hospital daily requirement of
nurses and compared this against actual numbers creating a RAG rated spreadsheet that is easy
to use and easily identifies hotspots with time to rectify any concerns. Hayley Blandford Clinical
Matron and the Clinical Matron Team.
Staff Testing: Rapid implementation of staff COVID swabbing
service at the beginning of the surge allowed us to adequately
manage our vital staff resource more effectively. The team
were brought together from all over the Trust and set up a
drive through testing unit as well as a clinic so that staff were
able to get a swab within a few hours of requesting a test.
The Lasham Unit has evolved to undertake and process
antibody screening and is the one-stop-shop for advice and
support related to testing. Sue Hurst Clinical Practice Educator,
Philippa Aslet Lead Cancer Nurse and the Lasham Team Falls
Awareness.
Common themes found in Serious Incidents relating to falls
with harm have been publicised by our Falls Lead in a way that
has been understood at all levels of the organisation. Posters,
education and communications around policy reminders such
as the use of the correct equipment to use when a patient has
an unwitnessed fall have embedded resulting in a positive
change in the way we work. Charlotte Pearce Falls Coordinator
Louise Fox – Associate Director of Nursing,
Hampshire Hospitals Foundation Trust

6. Set up of a COVID recovery ward for older people suffering from mental health conditions
What did you do?
Prior to the pandemic, Beechwood Ward was a functional older person’s ward, however, this then changed to a Covid recovery ward for older
people suffering from mental health conditions. Beechwood Ward accepted older persons that had a confirmed diagnosis of Covid 19, and
nursed these individuals through this illness.
What hurdles did you have to overcome?
The staff needed to up-skill very quickly, we had input from a multi-disciplinary team, such as frailty specialists and palliative care nurses. Staff
needed to learn a variety of new skills and also deliver care at its highest standard whilst working in full PPE (level 2 PPE).
Staff were required to change their shift patterns at very short notice.
Due to the pandemic and the physical health of some of the people that the Beechwood staff cared for, unfortunately some passed away, this
was a challenging time for staff, and however they managed this with empathy whilst maintaining dignity throughout.
What was the outcome/benefit for Patient Safety?
The outcome for us was very positive, we were able to nurse people back to good physical health, however we had 2 people that
passed away due to Covid 19.
We received a lot of thanks and positive feedback from a variety of teams and families, we had a visit from Nick Broughton (CEO),
who also highlighted the good work he has seen on Beechwood in his “BLOG”.
Patient safety was ensured at all times, if the nursing team were unsure of anything, they would consult with specialist as to ensure
patient care was delivered to its highest standards.
I could not be prouder of the team I am privileged to work alongside, they have acted in a professional and empathetic manner
throughout, they have adapted very quickly, not one member of the team went off or raised any complaints. In fact they were all
amazing.
Elaine Gomez – Ward Manager, Beechwood Ward – Southern Health

7. Adaption of Outpatient Service to meet new need due to COVID 19
Russell said… I have been working with this team (Lymington New Forest Hospital
Outpatient Department team) for a couple of months now and I am extremely
impressed with their focus on patient safety, but not letting that become an excuse
for not providing as much service as possible.
What did you do?
Lymington New Forest Hospital Outpatient Department had to ramp up from
minimal running during the height of the Coronavirus emergency
What hurdles did you have to overcome?
Understanding Government guidelines alongside local NHS Trust directives
Understand what those guidelines meant in terms of a safe spatial capacity model
Patient and staff reticence to return to a hospital setting.
What was the outcome/benefit for Patient Safety?
We reviewed face to face OPD clinics and continued only those that were absolutely necessary.
After initially slowing the rate at which patients were being seen, clinicians opted to use the
teleconsultation model for communication and engagement with patients. This proved to be very
effective in most clinics, resulting with us tracking well ahead of national targets.
The department engaged with the Quality Improvement resource, undertaking training to ascertain
how to safely increase activity without endangering either staff or patients. The phrase “Get back to
better” was adopted from one of our dietitians.
Significant work was undertaken to understand what really happens in the department, rather than
the imagined state that we mistakenly tend to assume. This led to changes in patient flow and the
way in which patients were managed throughout their visit to the hospital. These changes were
continually revised as circumstances changed.
For example:
- We screened patients temperatures at the door
- Controlled entry to the hospital - need only basis
- Issued masks to patients
- Collaborating with another Trust, identified and implemented a phlebotomy appointment system
replacing the riskier ‘walk-in’ system.
Russell Slater, Lymington New Forest Hospital Outpatient Department team

8. Deliver patient education pre-operative session prior to cancer surgery, whilst reducing risk of frequent attendances to acute site
during pandemic
What did you do?
Surgery School MDT face to face patient education preoperative session was
discontinued. Major cancer surgery continued with even greater need to improve health
and reduce LOS in hospital.
Aim: Maintain service whilst reducing risk of frequent attendances to acute site during
pandemic
Method: Patients offered either 1 hour telephone consultation or F2F individual session
either side of a pre-existing appointment. Equipment (including exercise DVD,
spirometer and booklet) was given to or delivered to the patient.
Domain acquired (surgeryschool.co.uk) to upload key information and a series of films
about prehabilitation, preoperative and post operative care were recorded to
compliment virtual and face to face Surgery School sessions.
What hurdles did you have to overcome?
Telephone consultations
-time consuming ( 1 hour/patient cf 2 hour session for 10 patients normally)
-challenging if hard of hearing
Delay in delivery of equipment due to disrupted postal service
Finding adequate space on site to consult patient
Normal routes for prehabiliatation inaccessible (gyms, classes etc) so DVD and
NHS Exercise promoted
Co-ordinating MDT and finding a location to record films
Communication with remote MDT challenging
Post op patients not in normal location so nursing staff less familiar with care.
Staff education
delivered by POM nurse
Patient related:
No peer or visitor support for patients – POM nurse supportive visits post op
Financial:
No increase in funding to purchase domain. Private resource sought
What was the outcome/benefit for Patient Safety?
Maintenance of a valuable service during challenging times.
No significant change in LOS for this patient cohort during Covid
Staff support by POM nurse to ensure early post op goals met with
improved
MDT working
Development of new online resource with future benefits
Sr Charly Bellis, Dr Sarah Marstin - Queen Alexandra Hospital
Portsmouth

9. Time to ACT (TTACT)
What did you do?
The Time to ACT (TTACT) team:
• Developed and launched a deteriorating patient pro forma and educational package across the
Trust between Dec 2017 and June 2018
•Formed a buddy system with the wards allowing continued support so improving care and
safety
•Gave targeted support to wards to improve vital signs compliance
•Developed a dashboard giving real time feedback to ward managers regarding monitoring
compliance.
•Developed a process of bespoke monitoring for certain patients (limited observations)
What hurdles did you have to overcome?
•Implementation of NEWS 2 into a 1100 bedded acute hospital
•Project roll out across 38 adult in-patient areas
What was the outcome/benefit for Patient Safety?
Following the launch of TTACT there was:
Sustained improvement in the escalation of deteriorating patients with better clinical
documentation, particularly escalation planning
Roll out of a Treatment Escalation Plan form in March 2020
Improved compliance with observation monitoring - sustained even through the pandemic
Monthly data collection providing oversight and assurance internally and externally
A fall in the number of cardiac arrests per month – sustained even during the pandemic
Nicola Sayer & Sara Blakeley on behalf of the Time to ACT team
– Portsmouth Hospitals University

10. Implementation of BSOTS – a maternity specific triage system
What did you do?
We had to improve our triage system following our CQC inspection.
We implemented BSOTS a maternity specific triage system During the height of the Covid Pandemic.
We trained 91 staff over a period of 2 weeks launch the service within 1 month.
The positive impact to our service was immediate.
What hurdles did you have to overcome?
Learning via virtual training usually you would attend a study day in Birmingham. Due to Professor Sara
Kenyon working from home due to Covid she was able to support virtual training. We had weekly
session to discuss and plan implantation.
We trained 91 Portsmouth staff member for the launch in a 2 week time frame including all Dr’s and
core midwives, this kept momentum and engagement in the project.
Waiting long periods for study days.
Sharing learning Wessex wide quickly and effectively.
What was the outcome/benefit for Patient Safety?
90 of women are triaged within 15 minutes of arrival to the Maternity assessment unit.
They are categorised to the level and time frame of care required.
Women are reassured and accepting of their on going care plan.
Professor Sara Kenyon “You are an example of excellence”.
We have shared our success story Wessex wide and how we implemented the training and now other
units within Wessex have been trained with Sara. This would have not been possible without the
restrictions the Covid pandemic introduced.
We have had no adverse outcomes since implementing this system in our MAU.
The working relationship between obstetric and midwifery is much improved due to the shared
language and efficiency of the system.
Alison Scannell, MatNeoQI PHT Trust Lead - Portsmouth Hospitals University

11. Creation of Trust Induction for pre-registration healthcare students supporting the
workforce during COVID pandemic
What did you do?
We employed over 100 pre-registration
healthcare students to be part of our workforce
during the Covid pandemic.
All of these students had volunteered for this,
but had mandatory skills and competencies to
complete whilst on placement with us.
What hurdles did you have to overcome?
•Ensuring a quality learning experience
•Maintaining their health and wellbeing
•Supporting their learning needs
•Placing them appropriately to support the
workforce
•Maintain effective communication with over
100 students whilst on a reduced staffing
template due to redeployment
•Support students opting into a placement
with us who usually undertake their clinical
placements in other trusts.
What was the outcome/benefit for Patient Safety?
•We created a 3-day bespoke Trust Induction. Whilst the majority of our students
on the paid placement model were familiar with the Trust, this would be the first
time they were part of the workforce and not in supernumerary placements. The
bespoke induction addressed key and topical workshops including: Respiratory
care, A-E Assessment, Care of the Dying Patient, Last Offices, FIT testing, Donning
and Doffing, Proning etc. They also undertook bespoke BLS and Manual handling.
This was evaluated very well and the students entered to workplace feeling fully
prepared and ready to undertake new challenges associated with Covid-19
•We ran two face-to-face drop-in sessions and a daily virtual drop-in for all
students each week. This ensured that the students had a point of contact every
day for any concerns or personal pastoral needs they may have had.
•We created a SimWard. This innovative teaching model was approved by the
local university and the NMC and allowed us to provide on-going training through
simulation. This enabled the students to continue working towards their
mandatory skills and competencies, whilst addressing topical issues. This was
very well attended and evaluated. The SimWard was situated in a closed ward
area and the students rotated around different scenarios which developed their
leadership and management skills, alongside patient safety and care planning
skills.
•Each member of our Student Support Team was a named Practice Assessor and
Practice Supervisor on each of the student’s portfolios. This enabled us to have
sight of their progress and to encourage feedback and assessment of skills in
practice. We were able to pick up any concerns early, and support the clinical
areas in the student’s development
Alice Girling, Education and Training – Royal Bournemouth & Christchurch Hospitals

12. Helen’s story
What did you do?
Introduced a new online learning resource to 232 nursing students
‘Helen’s Story: Insights into the healthcare experiences of a woman
with cerebral palsy, Part 1 Hospital Admission – Hi! Morning Helen’
What hurdles did you have to overcome?
Rapid transition from face-to-face to online teaching using new
technologies to support nursing students’ ongoing learning and
development during lockdown.
What the outcome/benefit for Patient Safety?
• Drew attention to the three-fold increased risk faced by patients with communication
disabilities of experiencing a preventable patient safety incident
• Emphasised nurses’ and healthcare workers’ legal and professional duty to identify, record and
act on every patient’s communication needs
• Demonstrated the significance of knowledge, self-awareness and empathy to effective
communication, person-centred practice; patient safety and outcomes; and analysis of poor
practice and patient safety incidents.
• Promoted better understanding of cerebral palsy and the various ways the condition can affect
individuals
• Enabled students to critically reflect on their approach to patient care and the influences
shaping their attitudes and behaviours; including any stereotypical views and assumptions that
might adversely affect their practice and inadvertently increase risk to patients.
• Good news/successes: positive impact on learning as reported by students; evidence of wider
potential e.g. local and international requests to share resource i.e. with Occupational Therapy
and Physiotherapy programmes, and the open access Virtual Empathy Museum, University of
Technology, Sydney, Australia.
Dr Sue Baron, Department of Nursing Science,
Bournemouth University
Link to open access version of the resource ‘The Empathic care of a person with cerebral palsy
e-simulation’ hosted in the Simulation Room of The Virtual Empathy Museum launched by the
University of Technology, Sydney, Australia: https://www.virtualempathymuseum.com.au/ then
click on Simulation Room and the following image

13. Accelerating the adoption of Placental Growth Factor (PIGF) based testing
What did you do?
Placental growth factor (PlGF) based testing has been recommended for use by NICE Diagnostic Guidance (DG23)
and Clinical Guidance (NG133) and is supported by the NHS Accelerated Access Collaborative and Innovation
Technology Payment programme. The AHSN Network is working to spread and accelerate the use of PlGF-based
testing. Locally, across Wessex, there are four trusts who have adopted this test – Poole, Salisbury, HHFT and IoW.
PlGF-based testing has a high negative predictive value (rule-out) for pre-eclampsia meaning women who receive a
negative result can be safely sent home (note: decisions are made along with other relevant clinical information).
This reduces the number of expectant mothers requiring a hospital stay.
What hurdles did you have to overcome?
Updated guidance issued by RCOG for healthcare professionals on COVID-19 infection in pregnancy recommends
that steps are taken to reduce the contact time of vulnerable pregnant women within secondary care.
In April, the AAC national working group on PlGF-based testing, supported stakeholders in the maternity system to
adapt, continue, scale up or begin efforts to implement PlGF-based testing amongst expectant women - helping to
keep women out of hospital during the COVID-19 pandemic.
What was the benefit/outcome for Patient Safety?
This is a way of safely and efficiently reducing unnecessary contact and possible spread of the coronavirus within
secondary care and during hospital admission.
Suzi van Es & Joe Sladen, Wessex Academic Health Science Network

14. Bay Safety Checklists to reduce incidents of aspiration
What did you do?
In response to 3 similar incidents within a 2 month period in
Neurosciences relating to aspiration where there was either no suction
tubing at the patient bed space or no yankeur we introduced bay safety
checklists.
The checklist to be completed in the morning, it is 3 simple tasks for each
bed space:
• Check suction- working/ equipment available
• Check oxygen- working/ equipment available
• Check bed space is clear and accessible
The nurse in that bay then has to put initials in the box. The bay safety
check list is stored in a covered window file at the entrance to each bay/
side room
What hurdles did you have to overcome?
Change in practice was difficult as people are not always willing to perform
extra tasks. Ward managers, sisters and charge nurses were asked to help
share the learning and importance of such important equipment.
Prior to the introduction of the checks a survey was completed on each
ward and there was no consistent answer of when the oxygen/ suction
was last checked. No staff knew exactly when it had last been checked
even in the acute bays. There was no consistent time it was checked nor
was this documented anywhere.
What was the benefit/outcome for Patient Safety?
Now it has been incorporated for some months it is becoming a part of the ward
routine.
An audit of compliance was completed and generally this was good. It did identify an
area for improvement but this was then fed back to the ward in question. Other wards
were 100% compliant.
Since the introduction of the safety checklist we have not had one reported aspiration
nor incident with no oxygen available
Katie Hammond – Neurosciences, University Hospital Southampton