Wessex cross-system Patient Safety Incident Investigation (PSII) thematic review

A total of 27 anonymised reports from ten organisations were included in the review which followed a structured, deductive approach, using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, to identify patterns across a wide range of incident types. Patterns were identified that highlight links or common and recurring factors which can be used to inform improvement priorities within the systems.

Three overarching themes were identified; ‘Communication that connects’, ‘Robust systems, safe care’ and ‘From roles to goals’. These themes reflect the dynamic interactions between people, work done, systems, and organisational culture.

To support safer care and stronger, resilient systems the recommendations from the review include:

Building on existing improvement initiatives, including those supported by the Patient Safety Collaboratives, by aligning activities with the three overarching themes.
Identifying gaps in current processes and using the themes as a region-specific framework to guide future incident reviews and improvement planning.
Routinely adopting a thematic review of PSIIs as a valuable exercise for cross-system learning and improvement.
Exploring opportunities to replicate the review in other geographical regions or in specific specialties.

Watch the video below to hear the team talk about why and how they carried out the review, where it was shared and some of the improvement work it has lead to.

The whole review can be seen here.

Meet our Innovation adoption team

Caroline Thomas

Innovation Adoption Programme Assistant

Caroline is a Programme Assistant for the Innovation Adoption team, having initially joined our Patient Safety team in April 2018.

As a Programme Assistant, Caroline has worked across the Insight, Medicines Optimisation, Patient Safety and corporate programmes providing project support and events management expertise.

Her background is in health insurance, and for 12 years she worked for one of the largest insurers in the world in claims management. During this time she gained experience in carrying out independent medical assessments, financial reviews and investigation of fraudulent claims.

She also has experience in staff coaching, occupational rehabilitation, recruitment, communications and implementation of small and large-scale change in both current and previous posts. In addition, she has experience in website management including search engine optimisation, sales and complaints handling.

Caroline is passionate about supporting teams to effect change for the better and is PRINCE2 certified.

Leah Gallon

Associate Director - Innovation Adoption

Leah Gallon is the Associate Director Innovation Adoption and is overseeing the Cardiovascular Disease (CVD) programme, Medicines Optimisation programme and Primary Care programme.

Leah joined the organisation from an acute NHS trust where she was the Clinical Service Manager for Therapies, and during the Covid pandemic worked as Silver Command and the Trust Covid Operational Lead.

Prior to this she has worked in both acute and community NHS settings around Hampshire.

Leah is a respiratory physiotherapist by background. She has worked in a variety of roles including clinical, operational, transformation and programme lead. She has delivered large scale projects, across systems and has been involved in improving patient pathways, bringing in new digital options and ways of working.

Leah is passionate about making a difference in the NHS after starting her career as a physiotherapist and wanting to improve the quality of care for patients. She is using her skills developed across various roles to make a wider difference within the NHS across the Wessex region.

Heather Stacey

Senior Programme Manager Innovation Adoption

Heather initially joined Health Innovation Wessex in February 2021 to support the Mental Health Safety Improvement Programme and Managing Deterioration (Children and PEWS). Since then, she has moved to the Innovation and Adoption Team, with a focus on supporting the Dorset system.

She is an Occupational Therapist, completing her training in London, before moving to Edinburgh and then Dorset in 2007. Heather has a Masters in Advanced Mental Health Practice and has worked within the NHS for 30 years, mainly within mental health services in most settings including acute assessment, community and outreach posts - working clinically and in leadership roles.

She undertook an HEE-funded Patient Safety Fellowship which focused on learning from staff reflections to focus on how patients and families are supported around the time of death. Heather is keen to address the key themes from this within her work: improving system working, communication and staff wellbeing. She has just completed her ILM level 5 coaching qualification.

Simeon Kent

Innovation Adoption Programme Manager

Before joining Health Innovation Wessex, Simeon was working in one of the UK's Lighthouse projects setting up an automated Covid-19 mass testing facility in response to the Covid pandemic. Simeon's role within this team was as the Laboratory Operations Manager, ensuring the streamlined implementation of automation including liquid handling robots and loop-Mediated Isothermal Amplification (LAMP) technology.

Before this he was working with Southampton Primary Care Ltd as part of the Business Development and Support team who pioneered the 'out of hours' primary care service using 'Hubs' for Southampton.

Simeon is passionate about pioneering technologies and even more passionate about seeing them used to improve the experience of NHS patients.

Jo Murray

Associate Director Innovation Adoption - Strategic Programmes + Patient Safety Lead

Jo Murray is the Associate Director for Innovation Adoption - Strategic Programmes and Patient Safety Lead. She has a portfolio of projects delivered through the Wessex Innovation Adoption and Wessex Patient Safety Collaborative teams, including cardiovascular disease and the national priorities laid out in the NHS Patient Safety Strategy covering deterioration, maternity and neonatal, medicines, and system safety improvement programmes. She is also a national co-lead for the maternity and neonatal workstream.

Jo joined us from Oxford AHSN (now Health Innovation Oxford and Thames Valley) where she was the workstream lead for sepsis and deterioration for five years. During the pandemic she played an instrumental role in the Covid Oximetry @ home project. She has a clinical background, working as a Respiratory Physiotherapist in several London teaching hospitals before moving to Hampshire and beginning her journey in patient safety and clinical governance at Hampshire Hospitals NHS Foundation Trust. She is trained to Masters level in patient safety, quality improvement methodologies, facilitation and network weaving and is an ILM level 5 coach.

Jo is passionate about adding value and working collaboratively to achieve service-user centred care.

Fiona Robertson

Programme Manager Innovation Adoption

Fiona is a programme manager within Wessex Patient Safety Collaborative, and within Nationally Prioritised Innovations for Asthma Biologics.

Fiona is a registered nurse with 17 years’ experience working in the NHS. She has spent her career working in several London trusts both in Emergency Departments and Critical Care Units in a variety of roles. During this time, Fiona developed a passion for patient safety and patient experience whilst developing her clinical expertise. In 2017 Fiona took a career break and completed the Clipper Round the World Yacht Race before returning to London to undertake a new role as the Major Trauma Service Lead for south-west London and the wider Surrey and Sussex region.

During the Covid-19 pandemic, Fiona decided to move out of London and back to the south coast. She is looking forward to spending more time outdoors and being nearer to her family.

How can we help you?

If you’d like to get in touch please
email enquiries@hiwessex.net