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I’m a critical care outreach nurse in Brighton, I also work for the charity Patient Safety Learning. I recently completed a Darzi Fellowship which had a focus on learning from deaths and serious incidents, and it made me think: why are we not sharing learning?

I was frustrated at how recurrent harm is persistent in our healthcare system and wanted to take a practical approach to attempt to ensure harm doesn’t keep happening. Working both clinically and within Patient Safety Learning seemed to be the perfect fit.

Patient Safety Learning has established six evidence-based foundations for actions to address the causes of unsafe care. These are: shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture. These foundations form the basis of our latest report, A Blueprint for Action.

In our report, we propose the actions needed within each of these six areas both actions for organisations to take, and actions that Patient Safety Learning will take.

Shared learning for patient safety

In our previous report, A Patient-Safe Future, we made the case that healthcare is systematically poor at learning from harm. As a result, different patients will suffer the same kinds of harm over and over. Even when we do find effective solutions to prevent avoidable harm, these are shared slowly, and patients continue to suffer harm from problems that others have already addressed.

If we are to secure a patient-safe future, we need to find ways of learning how to deliver care safely, as well as avoiding harm. (In the jargon, we have to embrace and build on both Safety I and Safety II.)

If patients are to be safer, we need people and organisations to share learning when they respond to incidents of avoidable harm, and when they develop good practice for making care safer.

In a patient-safe future, we will see patients, clinicians, managers and health and social care system leaders share learning about safety practice and performance to make care safer.

Patient Safety Learning’s the hub

Patient Safety Learning also has a role to play, and we want to facilitate the improvement of shared learning for patient safety. As part of this, we have created the hub, an online platform and community for people to share learning about patient safety problems, experiences and solutions.

the hub allows people to learn, share and develop key ideas and techniques to improve patient safety. It fosters communities of interest and gives people a safe place to discuss issues that may be of interest or concern to them. It provides a collaborative environment for people to come together to build on improvements that have already begun and adapt solutions for local implementation.

How you can get involved?

the hub was launched at the Patient Safety Congress in July this year. It’s currently in beta, and we want to encourage everyone in healthcare to sign up as a member and begin using it. Your participation and feedback will be hugely valuable to us as we prepare for the full launch at the Patient Safety Learning Annual Conference on 2 October. the hub is free of charge for use by everyone including clinicians, patients, managers, policy makers, regulators, researchers and members of the public.

We will nurture and grow the hub. We want users to find it valuable and stimulating, so we will:

  • Provide editorial support to source, curate, commission and develop content
  • Support users in their conversations and ensure that for critical elements, such as descriptions of tools for patient safety, certain quality standards apply
  • Support and encourage communities of interest to share knowledge and support each other
  • Explore ways for organisations to use and support the hub
  • Connect the hub to other sites to give our users the widest possible access to learning for patient safety.

Will you join us in our aim to improve patient safety by sharing your learning, learning from others and working in collaboration with others in healthcare? Register for the hub now to join this growing community and play your part in improving shared learning.

I am more than happy to help you upload any content, start a conversation or just answer any questions – please get in touch with me.

Comments

  1. Claire,

    I like your blog and I like your hub. I'd be interested in your views on the following: What is the relationship in patient safety, what the NHS call quality, and what the rest of the UK call quality? This is an area that I'm very interested in and I have a view that if the NHS could understand this relationship then this would help to address the 'recurrent harm is persistent in our healthcare system' you refer to in your blog. If your hub is interested in defining this relationship then I'd love to join.

    Regards

    Tom

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