About dghealth

dghealth has been established to provide an opportunity for all employees of NHS DG to blog and share ideas and opinions and start conversations. There will be a weekly post. All blogs will be the personal work of the contributor and NOT official NHSDG policy. NHSDG have an Information Policy doc available on the Hippo website under useful I.T. forms

Being Wrong by Jeff Ace

Being wrong is interesting isn’t it? When you get a call right, your view of the world is unchanged and things are happening much as you expect them to; all very unexciting. But when you’re wrong, there’s something off with your perspective, or lacking in your knowledge; very interesting indeed.

Luckily, I’m wrong particularly often and accumulate large numbers of these excellent opportunities for learning. I’ve been wrong on some big life stuff and on too many professional and work related decisions to keep track of. I was even wrong in recent attempts to help my daughter with her physics homework, leading to her claim that many of the elements hadn’t been discovered when I was in school.

There’s something in this unfunny and (mostly) untrue teenage sarcasm that I think explains one of the common causes of ‘wrongness’ in that people look to the past to explain the present and predict the future. This might be fine but most of us, including my daughter, have an absolutely lousy sense of historical perspective. Smart Alec history teachers will use any number of examples to highlight how poor this perspective can be. A couple of my favourites in this list of things that just don’t seem right are that Cleopatra lived closer in time to ‘Carry on Cleo’ than to the building of the Great Pyramid at Giza, or that Tyrannosaurus Rex was more a contemporary of Marc Bolan than it was to the Stegosaurus. Similarly, England’s 1966 world cup win is as close to the outbreak of WW1 as it is to the present day, despite it being mentioned every four flipping minutes over the summer.

Broad contemporaries: T-Rex and T-Rex

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These examples show that people tend to distort historical perspective by magnifying the recent past and diminishing periods further back. So, to me, my schooldays of the 70s and 80s are useful reference points in understanding how the world works and will continue to work, whilst to my daughter it was when we learned to alloy copper and tin to make our swords. This phenomenon has big implications for how we get things wrong (or how we can avoid making mistakes).

Take climate change, for example. The scientific consensus is that we’re now heading for more than a 2 degree temperature rise on pre-industrial levels and likely implications include 3 metre plus increases in sea level rises. By all rational measures, this information should be dominating the political and economic agendas, with urgent risk management and mitigation measures everywhere we look. But 3 metres… that can’t happen, can it? That would swamp St Helen’s cricket ground in Swansea where Sir Garfield Sobers became the first human to hit six sixes in an over, where all great Welsh cricketers have strutted their stuff over the years (well yes I have played there, actually. Don’t like to go on about it. It’s not like there’s a framed picture in my house of me on the pitch or anything like that *). The scale of this change, that would flood Miami and make the Mumbles Road end at St Helen’s appear only at low tide, is way outside our historical reference points, our ability to visualise the world; so we sort of file it somewhere in our brains and get on with more everyday routine problems.  

St Helen’s Swansea – spiritual home of Welsh cricket

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So I worry about how our tendency to rely too much on a poor and distorted understanding of the past can make us wrong and complacent over big changes. And I worry about it a lot in the context of health and social care provision. 

Our historical perspective here is dominated by the post war model of service provision. This model is an historic anomaly, of course, radically different from that which existed through the rest of human history, but is nonetheless now seen as an unchanging piece of how our bit of the world works. The difficulty is that if you start projecting the next 20 years of demographic change, workforce availability, technology driven cost increase and the amount of funding that an economy can generate for health and care… it’s really, really hard to see how it all holds together to provide the sort of health and care service that people of my age will by then be expecting. I think there’s a tendency to dismiss these forecasts because, well the Health Service has always been short of money hasn’t it, and winters are always a bit tight, but we always get through it in the end…. and basically because our perspective doesn’t help us to imagine a radically different future. 

This I think would be terribly complacent and would open up our largely wonderful but already creaking system to existential risk. But whilst I’m a bit of a worrier, I’m also a mostly optimistic type of bloke. There is now a lot of work ongoing on the sorts of disruptive changes that could help to address the apparent perfect storm of pressures building on health and care. Organisations like The Kings Fund have been busy in this field lately (https://www.kingsfund.org.uk/publications/eight-technologies-will-change-health-and-care and https://www.kingsfund.org.uk/publications/digital-change-priceless are good examples) and show how we can move perspective from a future of tweaking our models of care to one where they are genuinely transformed. 

I’m wrong about loads of things but I’m pretty confident in predicting that, in order for us to continue to deliver the service our population deserves, we’re going to have to increase the pace of change to models radically different from those established. In D&G we have an outstanding track record of managing major change and this is one aspect of the past that I think is going to be extremely useful in preparing us for the future…

 (* ok there is)

Jeff Ace is Chief Executive Officer at NHS Dumfries and Galloway

Always look on the bright side of life by Ken Donaldson

I published this post on my own blogsite two years ago and, even though it is a little silly and dated, I thought I would share it with you again. Sadly things haven’t changed that much in the past two years.

“I don’t need to remind everyone that 2016 has been a particularly bad year. Who would have thought, 12 months ago, that we’d be leaving Europe, a complete Muppet (and that is an insult to Muppets to be honest) would’ve  been elected to the White House and far right, fascist, borderline Nazi rhetoric would suddenly become acceptable. Not me, that’s for sure, but here we are.

On top of all that we have daily news clips showing unimaginable suffering in Syria and other parts of the world whilst we sit watching helpless. And then there is all the celebrity deaths. It is as if the likes of Bowie, Rickman and Wogan knew it was all coming and thought “Stuff this, I’m out of here”.

So it is for that reason that I thought I would tell a wee story that may lift your spirits. Not much perhaps but hopefully, like me, you may have a smile on your face by the end of it.

A few weeks ago I had a bit of a crazy day trip down to London. Up at 4.30 to catch a train from Lockerbie to Euston, full day finishing at 9.30 (well, when I say ‘finishing’ that was the work bit, I then caught up with friends over some red wine until 1am…I never learn). I had to get up again at 4.30 to catch a return train to Glasgow. Forgive me a slight digression but the contrast between my two ‘walks to the station’ was quite stark. In Lockerbie it was a glorious, still, freezing morning with thousands of stars filling the jet black sky. In London it was slightly warmer walking down Tottenham Court road but there were no stars, just a plethora of homeless people shivering under blankets and, at one horrific moment, being investigated by the biggest rat I have ever seen. In fact the only rat I have ever seen outside of captivity. There was a somewhat Dickensian feel to it.

But back to my story. So I got on the 5.30 from Euston and promptly fell asleep. The next few hours were a bit of a blur but as we approached Preston the guard made his usual announcement – take care leaving the train and remember all your bags etc – but then he added “Ladies and Gentlemen I would like to take this opportunity to remind you that it is 36 days 15 hours and 43 minutes till Christmas. And with that happy thought here is a song” I must confess I was expecting a Christmas hit or carol but instead he played ‘Always look on the bright side of life’ by the Monty Python boys. I started to smile, I really had no choice, and as I looked up and down the carriage at my fellow passengers, folks who had spent the past 2 hours quietly reading the paper or tapping on their laptops and ignoring each other, I noticed that they were all smiling too. And some were staring to chat, probably about the song but who knows. The guard interjected a few times with “I want to hear you singing now” and before the chorus “Altogether now” which just added to the fun. And as the train slowed down and approached the platform the music stopped and he said “Ladies and Gentlemen, Preston” and that was that.

It made me realise the power of a small gesture, a simple thing which raised the spirits of a few hundred tired travellers. It also made me think that, sometimes, ‘Life is a piece of sh*t, when you look at it’ but Eric Idle was right, it helps to look on the bright side.”

KD 1

“Cheer up, Brian. You know what they say.
Some things in life are bad,
They can really make you mad.
Other things just make you swear and curse.
When you’re chewing on life’s gristle,
Don’t grumble, give a whistle!
And this’ll help things turn out for the best
And
Always look on the bright side of life!
Always look on the bright side of life
If life seems jolly rotten,
There’s something you’ve forgotten!
And that’s to laugh and smile and dance and sing,
When you’re feeling in the dumps,
Don’t be silly chumps,
Just purse your lips and whistle — that’s the thing!
And always look on the bright side of life
Come on!
Always look on the bright side of life
For life is quite absurd,
And death’s the final word.
You must always face the curtain with a bow!
Forget about your sin — give the audience a grin,
Enjoy it, it’s the last chance anyhow!
So always look on the bright side of death!
Just before you draw your terminal breath.
Life’s a piece of sh*t,
When you look at it.
Life’s a laugh and death’s a joke, it’s true,
You’ll see it’s all a show,
Keep ’em laughing as you go.
Just remember that the last laugh is on you!
And always look on the bright side of life

Always look on the bright side of life

Come on guys, cheer up

Always look on the bright side of life

Always look on the bright side of life

Worse things happen at sea you know

Always look on the bright side of life

I mean, what have you got to lose?
you know, you come from nothing
you’re going back to nothing
what have you lost? Nothing!

Always look on the bright side of life”

Lyrics copied from this site

Bully For You!! by Anonymous

image1I recently had the dubious honour of being at the receiving end of a bit of bullying behaviour at work.

It was not in my usual place of work, I hasten to add, and not by someone I normally work with. The details aren’t important, the issue was resolved as much as it could be but the after effects lingered.

It has caused me to reflect on the whole concept of what bullying is, who does it and how it affects not only the individual but the organisation as a whole.

Bullying behaviour does no one any favours. It demeans all those concerned and does nothing to resolve the issue.

My experience left me feeling initially shocked, then humiliated and embarrassed in front of my peers. As days went by I began to question my ability to do my job well. In the space of a few minutes I had gone from a fairly confident person to a bit of a wreck. So why do some people behave this way and what can we do about it?  I’m not sure to be totally honest, it’s a complex issue.

Within the NHS it is paramount that we work in a professional manner with patient safety at the heart of all we do, therefore constructive criticism is crucial. If something is not being done in the correct way then this should be challenged. This can be done without conflict in a non emergency situation. In an emergency however situation however, when the adrenaline kicks in for all involved, there may not be time to worry if someone has taken offence. There will be time for reflection later, when the event can be discussed in a calm manner, with all those involved, looking at what went well and what could have been done better. Any issues anyone has should be freely discussed, or if this is not possible then a one to one with the line manager may be helpful.

Abuse is not acceptable in any situation however, and we all have a duty of care towards each other to ensure this doesn’t happen. 

Bullying behaviour occurs for many reasons, often due to stress or fear, emotions are heightened and the definition of what unacceptable behaviour is can vary from person to person. That is why it is of such concern. There are guidelines in place highlighting what constitutes bullying and continued bullying needs to be reported and measures taken to resolve it as soon as possible.

Bullying takes many forms, not always overt, sidelining a person, rolling of eyes behind their backs, not giving a person equal opportunities with their peers to progress. We may have had this happen or even done it to others. Sometimes it’s so subtle that the person being bullied isn’t initially aware that they are the victim of ridicule. This is particularly cruel.

The cost to the NHS from stress related absence is enormous; there are recruitment issues in all areas, so let’s try to ensure that we are part of a welcoming, inclusive organisation that shows zero tolerance to bullying behaviour.

Now, don’t get me wrong, I’m not exactly a paragon of perfect behaviour myself and I’ve been sharper with folk than I should have been. You always know when you have done this…..it leaves a bad taste.  It’s certainly made me rethink my own behaviour, much to my husband’s delight!! 

With that in mind, I encourage everyone to think of someone in your own place of work that you don’t interact with much, they might even get right on your nerves, ask them about themselves, take a bit of time to find out who they are and listen. You might be surprised! One thing I can guarantee is that not only will they feel good, so will you.

For further information , I found the document on Bullying and Harassment in the Workplace at the Acas website very helpful. You can find it here.

If you feel you are being bullied or maybe complicit in bullying behaviour, now is the time to do something about it.

Kindness cost nothing.

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Memories…of the way we were… by Elaine Ross

Readers of certain age will remember the Barbara Streisand song in the 1970’s with the line  ‘Could it be it was so simple then…’

The way we were

The NHS 70th anniversary is a reminder of the major progress made over the last 70 years.  The reduction in the spread of communicable diseases such as measles or whooping cough, which lead to significant numbers of deaths and long term incapacity in years gone by, is just one of them.

My own Uncle spent years in a mental health facility following encephalitis leading to learning disabilities having contracted whooping cough from my mother as a baby.

Hand hygiene and vaccinations are, in my opinion, the two most effective ways of preventing infections.  Yet we are now seeing measles outbreaks and increase in whooping cough across the UK due to a lack of uptake of the vaccine.

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Whilst the essential elements of infection prevention and control have remained the same; preventing spread of microorganisms, advances in health care have led to increasingly complex procedures and equipment used on, often, more vulnerable patients.

Antibiotics were just available in 1948 but since then there has been an exponential rise in the number of antibiotics and the frequency with which they have been used, culminating now in a drive to reduce the number of antibiotics prescribed in a move to combat antimicrobial resistance, which is recognised as a global threat.

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The first infection control nurse E.M Cottrell was appointed in 1959 in response to an increase in methicillin sensitive Staphylococcus aureus (MSSA) in Torbay hospital. It commonly causes skin infections and may lead to sepsis through blood stream infections (bacteraemia). The methicillin resistant version (MRSA) was first reported in 1961.  It wasn’t until the 1980’s that Infection Prevention and Control nurses began to be appointed more widely as part of the plan to tackle the expected AIDs epidemic. In reality MRSA probably killed more people in the UK than AIDs in the late eighties and reached a peak in the early 2000’s where 40%of all bacteraemia were caused by MRSA. 

Effective hand hygiene and ‘universal precautions’ as they were then known, helped to combat MRSA however screening has had the largest impact and nowadays it is rare to have an MRSA bacteraemia. This year in NHS D&G there has been only one. 

The advance of technology

There have been many advances in technology which changed the face of frontline infection prevention and control. The development of liquid soap improved compliance with hand hygiene and reduced occupational dermatitis that had been scourge of many a nurse in the days of carbolic soap.

The advent of alcohol hand rub in the late 1980s has reduced the spread of infection as it is so quick to apply; new formulas are actually kinder on the hands and more effective against the majority of organisms than soap.

Laboratory techniques have moved from manual to automatic systems utilising, in some cases, molecular microbiology. Test results are available rapidly, sometimes within in minutes and allow the swift isolation and treatment of patients. In the early days of the NHS tests would have taken several days and longer for organisms such as tuberculosis. Some tests would have used animals. There is no need for an animal house in any laboratory in the NHS these days!

In fact technological advances have affected everything from cleaning to patient records e.g. Clinical portal and TOPAS and IC net connecting lab results and patient journeys.

Sterilisation using high-pressure steam may not be an option for example with highly expensive and sensitive equipment such as endoscopes. Neither can we soak them in toxic chemicals such as Cidex as we did in my days in ENT! 

As healthcare has developed so has complexity of equipment and systems to support it. It is vital that infection prevention control is involved in the specification and purchase of equipment used in healthcare.

More recently, to further reduce the risk from an environment that may have been contaminated by a drug resistant organism, sophisticated machinery has been developed utilising hydrogen peroxide vapour or ultraviolet light which can enhance the level of disinfection achieved within a room. This is a far cry from the Dolly Mop and bucket that would have been in use at the dawn of the NHS though microfiber mops and bleach still have their place. 

The advent of automatic washing machines revolutionised hospital laundry. 

The move to predominately disposable gloves and aprons negated the need for regular washing of these items  and no nurse will be found in the sluice scrubbing ‘Macintoshes’ or draw sheets as they were known when I started. 

The need for adequate ventilation and supposed benefits of fresh air were recognised in the early days of sanatoriums. These days ventilation remains important in preventing the spread of infection but the engineering around this has become ever more complex.

Airborne  isolation rooms are a far cry from placing your patient in their bed on the veranda.

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Lochmaben Hospital

What next?

We have reached a stage where there are organisms that are highly resistant to antibiotics and may find ourselves in a world where people are dying from common infections because the antibiotics we have won’t work. Prevention is better than cure, doing simple things like drinking more fluid to reduce urinary infections. 

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In healthcare it’s what YOU can do to prevent infection that will make a difference to patients and as at the dawn of the NHS in 1948, the fundamental elements and messages remain the same, clean hands, clean rooms, clean equipment.

Keep up the great work.

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Elaine Ross is Infection Control Manager at NHS Dumfries and Galloway

I can be high and I can be low by Anonymous

Anon 1I can be high and I can be low.  I can be flaky and little miss chatterbox too.

I can be nice and then snap on you making wonder what went wrong.

I used to think all of these qualities were embarrassing, shameful, inconvenient, then

When I was given my diagnosis I was still shameful never feeling relief that giving a

name or a reason to my behaviour was supposed to give.

How can I learn to love so many characteristics of myself whilst hating them at the

same time.

How can I feel happy that everyone thinks I am so unique, so funny but still be so sad

that they have no idea I’m just broken with a smile on my face.

I’m just laughing to keep from breaking.  That sometimes the energy and excitement

pouring out of me is my best quality and sometimes it is my worst.

What makes me unique is I can’t make it go away.  I can’t just calm down or perk up

when I am depressed.

Mental illness is not just being what you think or a state of mind you can control even

when I try my best.  For me that means it debilitates me until I can no longer work. Or

when I want to socialise with family or friends sometimes even getting out of bed.

I have had a great year or two in exchange for several months that are so dark I can

forget what the light looks like. Then at other times I can appear to live “normally”

having had a bad a couple of days here and that is easy for me to hide.

Given the alternatives I consider myself lucky.

In my head I am constantly going over the negatives the parts of a mental illness that

make me weak but other times I am fun.

I have heard from friends, colleagues you are hilarious and we always have a laugh.

That’s a quality I think Bipolar gives me because during a hypomania I can feel on

top of the world.  Yet not so “crazy” its obvious.

 

Anon

Anon 2

 

 

 

 

 

 

 

 

Patient Safety Group – PSG (not Paris Saint-Germain) by Emma McGauchie

Given that it is the year of the world cup we thought we would change our name to that of a football team.   For those of you (Eddie) who don’t follow football PSG stand for Paris Saint Germain and has a catchy ring to it!

Like some of these famous football players my job role as Adverse Events Co-ordinator is just as exciting!! I oversee the whole of NHS Dumfries and Galloway’s Adverse Events and risk.

I also co-ordinate the organisations Significant Adverse Event investigations and reviews and it was at one of the review meetings that I was put forward to write this blog – Cheers Ken!

I love to make the most of every opportunity therefore I thought I would use this blog to share with you some exciting changes you can expect to see over the coming year.

But firstly we would like to make a clear, public commitment to staff that our organisation supports an open and fair culture, by letting you all read a Key statement from our chair and  co-chair person, Eddie Docherty and Ken Donaldson (on behalf of Patient Safety Group (PSG))…….

“There is no doubt that over the years there has been a culture of blame in the NHS.

As chair and co-chair of the Patient Safety Group, we would like to see us move to a culture where we learn and improve from any failure.

It is our firm belief, that in a complex system like the NHS, it is often not the practitioner’s fault when things go wrong.

Staff will be treated fairly and supported to identify the failures in the system and improve service delivery.

We require ongoing honest reporting of concerns at the earliest possible stage to do what we can to ensure your working environment is safe. We would therefore ask all healthcare professionals to continue to raise all concerns in the appropriate manner predominantly by using Datix “.

 

During my first year as adverse event coordinator I found myself being asked two frequent questions, “Who are QPSLG?” and “What do they do?”

New name

Firstly the Quality and Patient Safety Leadership Group also known as QPSLG or “Quiggle Spiggle” have changed their name to Patient Safety Group (PSG for short).   We are confident this change of name will give a better understanding to everyone what we do.

PSG 9

 

Who are PSG?

Let me introduce you to a few of our members…..

Eddie Docherty

PSG 1As Executive Director of nursing midwifery and allied health professions I chair PSG. I am passionate about pushing the organisation forward as a learning environment, with a key focus on patient and staff safety.

 

Ken Donaldson

PSG 2For the past 8 years I have developed an interest in enhancing patients experience and ensuring staff experience is as good as it can be – which is difficult with current staffing issues and recruitment challenges. I believe my role in PSG is to ensure a balanced and fair approach to all serious adverse events and complaints. We need to focus on learning from error, improving systems and providing robust feedback – an area we are working on to improve. ‘To err is human…

Andy Howat

My role as the Board’s Health & Safety Adviser involves identifying, helping manage, reduce and control exposure to workplace hazards. With the ultimate aim of reducing the number of incidents, accidents and ill health in the organisation.

I work with teams helping them assess risks, develop risk reduction strategies, instigate changes in working practice, develop and deliver coaching/training, and offer advice on all aspects of workplace safety and occupational wellbeing.

I have been part of the Patient Safety Group for about a year now and I am regularly involved in reviewing significant incidents, considering the staff, patient and organisational affect these have and trying to enable the development of practical and pragmatic ways of reducing the likelihood and consequence but, ultimately the prevention of these incidents.

Stevie Johnstone

“My name is Stevie Johnston and I provide administrative support to PSG by not only co-ordinating the meetings but by working with others throughout the organisation to gather updates on incidents and investigations.  My knowledge around adverse events and the investigation process was limited but the group has given me the confidence to ask questions from a different perspective during meetings and the review process.  I have recently undertaken Adverse Events Training and look forward to putting this into practice in order to understand why errors happen, how we can stop them from happening again and how we can share learning in order to support others within NHS Dumfries and Galloway”

Linda Mckechnie  

PSG 3As Lead Nurse/Professional Manager, Community Mental Health Services, One of the most important things for me is to always look at what we can learn when things go wrong or don’t go as well as they should. This might be individual learning for staff, learning for teams or services, or learning across the organisation(s). Supporting staff when things go wrong is essential in order to encourage learning and reflection.

 

Emma Murphy

As Patient Feedback Manager, I regularly support Directorates with high level and complex complaints.  These complaints may be linked to adverse events or have other potential patient safety implications.  Sitting on the Patient Safety Group allows me to update members on relevant complaints as well as ensuring I have an overview of new and significant adverse events.   By building better links between patient safety and patient feedback, we can improve organisation learning and the patient experience.

Joan Pollard

PSG 4As Associate Director of Allied Health Professions I am the professional lead for AHPs and manage the Patient Services Team and the corporate complaints team.

I am curious about processes and culture, passionate about quality and love developing people and teams.

 

Susan Roberts

I am passionate about supporting staff to learn from errors, near misses or complaints to improve care and therefore my role as professional lead on PSG is a priority for me.  It’s not always easy for us to reflect when things go wrong but this process, if supported well, not only benefits patients it helps the staff involved too.

Christiane Shrimpton

PSG 5Associate Medical Director for Acute and Diagnostics, passionate about excellent patient care, keen to use any available opportunity to ensure we improve what we do and learn from situations that have gone well as well as those that have not gone so well.

 

Maureen Stevenson

PSG 6As Patient Safety & Improvement Manager I am passionate about making every day an Improvement Day. I passionately believe that creating the conditions for staff and our communities to learn and share together will enable us to together find practical solutions that improve the quality, the experience and the safety of health and care.

 

Alice Wilson

Deputy Nurse Director; I am enthusiastic about what I do and motivated by seeing things improve. I really want people to be open with service users/patients and to talk with colleagues about lessons they have learned from good and bad experiences so others can reap the reward, do more of what works well and reduce the risk of repeating the same errors.

 

And me 🙂

What can you expect…….

 

Learning from Significant Adverse Events (SAEs)

PSG 7We are producing Learning Summaries from all our SAEs and we plan to share these with each Directorate but we need these to be meaningful, therefore we would love to hear from you about what learning you have taken from SAEs you have been involved with and how you would uses such a summary.   Our first one is ready to distribute and should reach you all very soon so watch this space!!!

 

 

 

Patient Safety Alerts

 

PSG 8We have tested a process of distributing a couple of patient safety alerts one about patients being discharged home with cannulas left in situ and one about poor communication around the location of patients with telemetry in situ.  The patient safety alerts will come from the patient safety group, are produced as a result of urgent issues arising from SAEs or themes and are designed to make you aware of a potential risk to harm. So far they have been well received; therefore we will continue to produce these. The next one is on route ………

 

 

Monthly News Letters

We plan to produce a monthly news letter on a “theme of the month“. The newsletters are informed from adverse events reported on DATIX.  Our first edition is ready to go and we have a plan for future ones therefore again watch this space……

Plan for the future

We recognise all the hard work from each directorate in relation to managing their significant adverse events therefore we have put together a timetable for each directorate to provide us with their updates to enable us to support adverse event management in a timely and effective manner.

PSG 9.1

Communication

The Patient Safety Group is contactable via

dumf-uhb.Adverse-Incidents@nhs.net 

Emma McGauchie is the Adverse Events Co-ordinator for NHS Dumfries and Galloway

The Paper Boat by Patricia Cantley

Pat 1I’ve been reading a lot recently about the word Frailty and its importance within Medicine for Older People. We see a lot of frail people and as geriatricians they are our core business both inside and outside the hospital.

Healthcare professionals have debated over the last few years how to define Frailty, and even how we might begin to measure it. It is no longer adequate simply to shrug and say “we know it when we see it”.

From a patient or relative’s point of view however, the word Frailty seems to be at best somewhat vague and at worst, derogatory and demotivating. When we ask patients how they feel about the word, whether in large surveys or on a one to one basis, they do not like it.

One strategy that I have found useful over the years, especially when talking to relatives of the patients under my care, is to paint a picture that they can relate to by using a simple analogy. I’m sure others have used similar techniques – indeed I learnt this one from a consultant colleague many years ago.

So when I am talking to a family member about their older relative, I sometimes liken their clinical situation to a fragile yet beautiful paper boat sailing round a pond of their choice.

A while back I used this particular strategy for a very elderly man under our care who was going through a very complex and unstable time. At one point, there seemed to be a lull in the medical winds that were buffeting his fragile frame and I sat down with his daughter to chat things through. She was desperately seeking reassurance, but also wanting honest facts about what to expect over the months to come.

She smiled as I described my image of a beautiful paper boat, brightly painted and currently sailing proudly in the sunshine on the still pond, giving pleasure to all around. I explained that the difficulty was in not knowing what weather was ahead, and the problems forecasting accurately. If the weather were to remain fair with barely a trace of wind, then there was no reason to think that the boat would go down and indeed it might sail on for quite a while. If, on the other hand, the wind got up, or worse, if it started to rain, that frail wee boat would go over quite quickly with little we could do to save it.

As younger and healthier individuals, we react more like little tug boats of wood and steel… we would simply bob up and down until the storm had passed. Though a big enough hurricane could be too much for us too…

The chat developed a bit more as we translated some of this into more medical language and formulated a plan over what would and wouldn’t be reasonable things to try, should that wee boat capsize over in a high wind. We agreed that we’d want to try as much as we could, maybe including intravenous therapy but that at the end, a call to the family rather than futile attempts at CPR would be the right strategy. I noted it all down, and his daughter undertook to update the rest of the family.

As is the way in modern medicine, our paths diverged and he was discharged from our service. I didn’t keep in touch, though I knew his daughter had my mobile that she could call if she wished.

Many months later, a text came through…

“Dearest Trisha, I am sending this sad message to you to let you know that last night the paper boat went down in a storm. It was all very sudden at the end, but we were well prepared, and for that we thank you.”

I called the patient’s daughter later that afternoon and we chatted about what had happened. I don’t think we used the word frail at any point in her father’s journey, but she knew what we meant, and I think it did help. It was also lovely to be able to talk afterwards and listen to how the last chapter of the story had unfolded. It is rare as hospital doctors that we get to do this kind of post bereavement support and for me, it was well worth while being home a little late (again) that evening.

Every doctor I’ve met has tales of when things go well, and we all have our share too of when they haven’t. We must never be complacent, and a strategy that works with one family may not work with another.

We need to learn a lot of facts as doctors, but there is also an important place for the use of stories in medicine. We can learn and teach what has worked for us, and consider how others might adopt and adapt similar approaches.

I had another text, more recently, from a previous trainee. Also a happy story, they wanted to tell me of a scenario in another hospital in another city, where they explained to a family the fragility of another paper boat. Intense medically focused discussions had failed to convey the precarious nature of the situation, but the visual image of a brightly painted origami boat had been something of a breakthrough. I was touched by the kindness of the younger doctor that they thought to feed back to their former teacher in this way.

I’m still not sure what the best way to define Frailty is, but I’ve tried a few ways of describing it in the clinical situation. I’d love to hear tips from other people, in particular from patients and relatives, about what has worked best for them.

Patricia Cantley works as a consultant physician in the Midlothian Hospital at Home Team, offering an alternative to hospital admission for frail and older patients. She also works in the Royal Infirmary in Edinburgh and in the Community Hospital in Midlothian. She tweets under her married name of Elliott as @Trisha_the_doc

This blog originally appeared on the British Geriatrics Society blogsite on the 9th July 2018. Many thanks to Patricia for the permission to republish on dghealth.