Black box thinking 🤔 World Patient Safety Day #AskAboutAsthma

My audible book listening this week has been revisiting Matthew Syed’s book ‘Black box thinking’. Black boxes are electronic recording devices found in aircraft and support the investigation of incidents. Something I didn’t know was that they are actually bright orange, rather than being black to aid their recovery. What these boxes contain are clues, insights into what’s happened to ensure learning is extracted from situations and used to make changes to prevent incidents happening again. Whilst we don’t have the luxury of ‘black boxes’ in healthcare, what we do have is access to rich data and insight from a range of sources that, when shared openly, can help us get better at using insight to drive continuous improvement in healthcare.

I desperately want the care given to babies, children and young people to be of the highest quality, and to be consistently safe, appropriate and child centred, the reality is though there are always opportunities to learn and improve on the care we give. Throughout my career in nursing there are many examples where I’ve learnt so much from mistakes, bringing these to light, discussing the issues that contributed, then planning changes to increase learning, vitally help to prevent duplication of incidents.

The culture in which we operate is so influential in creating openness so that incidents are acknowledged, shared and learnt from. Of course nobody wants mistakes to happen, it’s not what we came into healthcare for, our aim is provide the best, most effective care in a timely manner, but we have to be courageous enough to share information and learning, in order to move things on. Supportive, encouraging cultures are vital for this.

Syed reflects on how success happens, he shares important lessons on how to expedite progress through learning and creativity. Practice of our skills is critical, the more we practice, the better we get and the more we learn. Syed challenges us to embrace failure on this journey, linking failure and success inextricably.

Professor Tony Warne @tonywarne in his blog ‘Safety first’ http://tonywarne.blogspot.com/2019/09/safety-first-is-always-good-strategy.html reflects on @NHSImprovement’s recent publication of the ‘The NHS Patient Strategy’ https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf

The foreword talks of achieving a ‘collective intent’ to secure commitment to improve the way we learn, treat staff and involve patients.

The strategy also highlights the importance of working with patient safety partners to drive improvements, the role of children, young people and families can be powerful, as they are such strong and effective advocates and drivers of change.

The other role the strategy proposes is a local patient safety specialist, I think there’s real potential to grow the Children and Young People’s patient safety specialist role and create a network of these post holders to share challenges and solutions.

The 17th September will see Patient Safety highlighted as a global health priority marking the first-ever World Patient Safety Day, led by the World Health Organisation (WHO). They will launch a global campaign to create awareness of patient safety and urge people to show their commitment to making healthcare safer https://www.who.int/campaigns/world-patient-safety-day/2019

So what are the issues we need to focus on in child health? Medicines management? I wonder if we can be using the Medicines for Children Resource https://www.medicinesforchildren.org.uk/ more? Pressure Ulcers? this remains a challenge in neonatal care http://nhs.stopthepressure.co.uk/ Early identification of deteriorating patients? Scotland have led the way on this http://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/surgery/paediatric-early-warning-score-pews/ and work by NHS England will follow. Identification of correct patients for procedures?

Something that’s having a real focus in London is ‘week 38’ the #AskaboutAsthma campaign, being supported by Asthma Nurse Specialists and the Healthy London Partnership Team @HealthyLDN. They are keen to get families and professionals involved in improving the care of children with Asthma, there’s lots of helpful resources that can be used by teams beyond London too https://www.healthylondon.org/our-work/children-young-people/asthma/ Do get involved and support the campaign.

It would be good to know what your priorities are as we all work to make care as consistently safe as possible. Let’s keep learning and sharing together.

Author: @kathevans2

I’m a Children’s Nurse who is passionate about improving healthcare and life with people who use services. I love getting out in the countryside or to the seaside to promote my mental health and well-being. On a journey to doing 100 marathons (slowly!) & part of team #NHS1000miles (new members always welcome!) I also love charity shopping, cooking and healthy eating too 😉 Sharing thoughts on a range of things that interest me. Comments, challenge, links to further thinking and research are most welcome. Learning and thinking together is always more fun!

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