Posted on: 5 September 2022
In this edition, we have a lot of great improvement news to share with you including:
Each month we will be sharing great examples from across CNWL where individuals and teams are improving systems and processes to ensure that we deliver the best evidence-based service user and carer experience where ever teams are delivering care across the trust.
Image source: World Health Organsiation
World Patient Safety Day @ CNWL
#WPSD2022 #WorldPatientSafetyDay
Medication Safety Theme
This year’s World Health Organisation (WHO) World Patient Safety Day will focus on “Medication Safety”.
WHO (2022) have highlighted that the ongoing COVID-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. WHO (2022) believes this to be a huge burden of harm, therefore “Medication Safety” has been selected as the theme for World Patient Safety Day 2022. The theme builds on the ongoing efforts of the WHO Global Patient Safety Challenge: Medication Without Harm. This campaign will provide much-needed impetus to healthcare system leaders to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use.
This year’s Call to Action is Know Check Ask – empowering Staff, Patients and Caregivers to understand the medication they are using, check what is not clear and access resources to increase their knowledge. As such, the trust will be highlighting existing resources and processes for staff, patients and carers to support and enhance medication safety.
We will be celebrating World Patient Safety Day on Friday 16 September with events and activities across the trust and will provide resources and information in the weeks until then. If you would like any resources to host an event in your team please email datixsupport-cnwl@nhs.net
WHO have also produced some campaign resources available on the WHO website including World Patient Safety Day logos, key messages, and campaign materials that can be accessed here.
“Safety is at the heart of all that we do here at CNWL and is the platform which supports us to deliver great care to our patients and their carers. World Patient Safety Day allows us to shine a light on all things safety related and to reflect on some of the outstanding work that is already being done across the Trust. Many teams have already made a Safety Pledge, but don’t worry if your team is still due to complete yours. This year the World Patient Safety Day focus is ‘Medication Safety – Medication without Harm’, which matches well with our safety strategy, perhaps your team might like to pledge on this subject.” - Jack Pooler, Assistant Director of Safety
Several CNWL Teams have submitted medication related safety pledges, including the Hillingdon Community Diabetes Service who pledged to complete a safety initiative on: ‘Ensuring that all patients who are eligible for an SGLT2 medication for their cardiac health are discussed at our joint working MDT with our Cardiac colleagues. This reduces the risks for hypoglycaemic events in diabetic patients already on medication to assist in the management of their diabetes.’
An update from Bal Sandhu, Team Lead is “we now have regular monthly MDT meetings with the community and secondary care Cardiac care teams to discuss the patients being considered for SGLT2 initiation for cardiac benefits. We have been proactive in preventing complications for those with diabetes and preventing LAS call outs for hypoglycaemic events. This innovative and joint approach to managing these patients has enabled timely medication reviews and ensured safety netting in this often vulnerable group of patients”
If you would like to make a safety pledge, relating to medications safety or otherwise, please contact a member of the Safety Team, or send the pledge form through to datixsupport-cnwl@nhs.net. This could be an ongoing, or planned project, you are working on, or a local pledge. If you would like to discuss, or know more about, safety pledges or the CNWL Safety Strategy, please call the safety team.
Shared decision making/overprescribing project
CNWL is undertaking a shared decision making/ medicines optimisation project with the aim to improve service users confidence and knowledge to discuss their medication during consultations with healthcare professionals. The project will promote a person-centred approach to consultations and shared decision making to move from a clinician’s agenda to a shared patient-clinician agenda.
There are various workstreams in the co-produced project to capture people’s views on the various components of medication consultations, including:
- the ability of service users to discuss their views about side effects, starting, stopping and making changes about their medication
- exploring HCPs understanding and views of patient centred communication and shared decision making and their implementation in practice
- raising awareness of the tools available to support reducing problematic polypharmacy and safe deprescribing
Improving medicines information using QR code technology
As part of a co-production project, CNWL partnered with QR Video Solutions to develop a series of videos combined with QR code technologies to educate patients, carers and healthcare professionals on valproate, lithium, clozapine and the Covid-19 vaccine. The videos, which have been accredited by ‘Choice and Medication’ and the ‘College of Mental Health Pharmacy’ have been shared outside the organisation across various ICS systems, with other NHS trusts nationally and some higher education institutes. Recently, the project has won awards for Excellence in the Use of Technology in both the Pharmacy Practice at the Clinical Pharmacy Congress and HSJ Patient Safety Congress.
The aim of the project was to create solutions that enable patients, carers and staff to effectively engage with medicines information. The QR codes for the videos are attached to the outer packaging of the respective medicines for any supplies dispensed via CNWL. Patients/carers can access the videos by scanning the QR code with any smartphone. Alternatively, the videos can be accessed here.
The QR videos developed so far include:
- Valproate: Considering valproate in women of childbearing age and helps support the Prevent pregnancy programme
- Starting lithium: Important information you should be aware of when starting lithium
- Considering lithium: Information to support decision-making about starting lithium
- Considering clozapine: Information to support decision-making about starting clozapine
- Clozapine and physical health monitoring: Information on why this is important and what you can do to help
- Clozapine and constipation: Information about constipation with clozapine and what to do
- Clozapine and smoking: How to avoid problems if you change the amount you smoke when taking clozapine
- Encouraging uptake and education about the myths around Covid-19 vaccine
Refer to our QR code poster for further details here.
If you have any medication safety improvement projects you would like to showcase, please contact the Medication Safety Team via cnw-tr.mso@nhs.net
In the lead up to #WPSD2022 this month we will be highlighting resources, events and activities that will be happening across CNWL to promote WPSD and medication safety. This year you will be able to follow what teams are doing both locally and abroad by searching Twitter for the hashtag #WPSD2022. If you would like more information about how you can get involved in WPSD activities then please feel free to contact the Patient Safety team at datixsupport-cnwl@nhs.net
If you would like to explore medication safety ideas for an improvement project with a member or our team please do not hesitate to get in touch with Geetika Singh, our Head of Quality Improvement at geetika.singh@nhs.net and we will be more than happy to help you.
Additional ways of gaining support are at our QI Clinic by contacting us at cnw-tr.improvementsupport@nhs.net and other educational opportunities here.
Thank you to the Patient Safety and Pharmacy teams for this month’s feature article.
References:
World Health Organisation (2022). World Patient Safety Day 2022. Available at: https://www.who.int/news-room/events/detail/2022/09/17/default-calendar/world-patient-safety-day-2022
This year’s all-day virtual Safety Conversation Day will be held on Thursday 10 November 2022.
We are busy developing the exciting programme and plan to have external speakers as well as speakers from across the organisation to share their excellent safety and improvement stories.
Applications are now open to submit a poster to receive an Improvement Award. The deadline for submissions is 5:00pm on 9 October 2022.
** Winners will be announced by our Chair at the Safety Conversation Day**
In May 2022, the Improvement Academy has introduced new Improvement Awards for teams that can evidence sustained improvement in CNWL services. The awards are recognition of excellence in improvement achievements.
Successful entries will receive:
- All submitted posters will be displayed on the Trust website.
- All teams submitting a poster will receive a certificate with names of the presenter(s) and author(s).
- Five winning teams selected by Improvement Academy faculty will a trophy.
- Improvement Award winning teams will be invited to showcase their work via a short presentation at the Safety Conversation Day event.
- The winners will be offered one to one coaching and support from the Improvement Team to write an abstract and submit them to an external national or international conference.
This will be a great opportunity for you to share the important work that you are doing to improve your services, celebrate your improvement work and share your learning with others across the Trust and externally.
Submissions can either be made in a poster format or a word format. For a poster template and information on how to submit click here. If you would prefer to submit in a word version, please click here.
Example posters from the last year’s Safety Conversation Day can be viewed here.
If you have any questions or to submit a poster, please email cnw-tr.improvementsupport@nhs.net, and Quality Improvement Team member will be in touch.
The QI Clinic is here to support your improvement ideas
Book time with us today to discuss 
We are excited to announce that we have listened to your feedback and have increased our QI Clinic time slots from 20 to 30 minutes. So take the opportunity today to book a QI Clinic slot while they are still available!
To book, send a request stating your preferred date and time to cnw-tr.improvementsupport@nhs.net and we shall confirm back to you with a diary invite and link to your QI clinic slot.
We look forward to speaking with you!
Useful Links
Contact information for Improvement Advisors:
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Diggory Division |
Peter Toohey |
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Goodall Division and Corporate |
Peter Smith |
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Jameson Division |
Bridget Browne |
- CNWL Improvement Academy Microsite: https://www.cnwl.nhs.uk/ia
- Life QI: www.lifeqisystem.com/
- If you want to get in touch please contact us here:
cnw-tr.improvementsupport@nhs.net - Follow us on Twitter by clicking: @CNWLImprovement