Supporting the largest safety improvement initiative in the history of the NHS
The South West Patient Safety Collaborative (PSC), hosted by Health Innovation South West, is helping to reduce risk of severe harm associated with maternity and neonatal care, medicines, deterioration, and systems in health and care.
Impact
During 2024/25 our work has fostered a culture of learning, collaboration and continuous improvement, enhancing patient safety across the system:
- Supported four acute trusts in the South West to test major patient safety initiative, Martha’s Rule.
- Continued to support the national spread and adoption of PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth), to transform the lives of vulnerable babies and accelerating perinatal working culture.
- Supported a whole-system approach across the South West to reduce harm from opioids for non-cancer patients, including through 20 pain cafes now running in Cornwall with many others running across the South West.
- Provided evaluation and learning insights to providers of PSIRF (Patient Safety Incident Response Framework) to understand its impact and boosted system capability.
- Trained 36 clinicians across all programmes in Bronze Level Quality Improvement.
Project summary
NHS England’s National Patient Safety Improvement Programmes (SIPs) aim to support and encourage a culture of safety, continuous learning, and improvement across the health and care system, helping to reduce the risk of harm and make care safer for all. They support five core areas of work: Maternity and Neonatal, Managing Deterioration, Medicine Safety and System Safety.
In 2024/25:
- Managing deterioration: We have supported four acute NHS trusts across Devon, Somerset and Cornwall to test Martha’s Rule to improve care for patients whose condition is worsening. In partnership with Health Innovation West of England we have co-delivered a Community of Practice to strengthen links with paediatrics. Meanwhile, we have continued stakeholder engagement with Devon Integrated Care Board regarding the PIER (Prevention, Identification, Escalation, Response) approach to enable effective management of acute physical deterioration out of hospital.
- Maternity and neonatal: We have continued to support implementation of Newborn Early Warning Trigger and Track 2 escalation toolkits (NEWTT2) and MEWS (Modified Early Warning Score) to reduce variation, increase standardisation and improve outcomes for maternal and neonatal care. PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth) is continuing to transform the lives of vulnerable babies and accelerating perinatal working culture across England and Wales.
- Medicines safety: We have been supporting a whole-system approach across the South West to reduce harm from opioids for non-cancer patients. 20 pain cafes are now running across Cornwall, with many others running across the South West, improving pain management for hundreds of people across the region. We worked closely with VCSE organisations and local ICBs to build momentum for collaboration, applying systems-convening expertise and contributing evaluation skills and measures. We also shared learning nationally, influencing uptake of the pain cafe approach.
- System safety: Patient Safety Incident Response Framework (PSIRF) initiatives are driving impactful change across the South West system. We have provided measurement and evaluation insights to providers to understand the impact of PSIRF, while enhancing collaborative learning through workshops and meetings and boosting system capability via training and events.We also delivered quality improvement training in SEIPS (Systems Engineering Initiative for Patient Safety) tools and rolled out a maturity assessment tool to seven sites to establish their baseline positions and key themes for targeted support.
Rationale
The National Patient Safety Improvement Programmes (SIPs) are the largest safety improvement initiative in the history of the NHS.
Key stakeholders
Health Innovation South West hosts the South West Patient Safety Collaborative (PSC), one of the PSCs across England delivering the National Patient Safety Improvement Programmes.
Next steps
- Managing deterioration: Supporting the development of local measuring plans for Martha’s Rule and increasing engagement among junior staff.
- Maternity and neonatal: Continuing to support PERIPrem within the South West and sharing learning regionally and nationally. Work will continue to implement MEWS/NEWTT2 escalation charts across our systems as digital systems come online.
- Medicines safety: Disseminating our new Pain Cafe Implementation Toolkit and video and supporting the set-up of a Pain Cafe Community of Practice in Devon. In 2025/26 the Medicines Safety Improvement Programme will focus on supporting systems to reduce harm from psychotropics prescribed to people with a learning disability.
- System safety: An informal community of practice will meet to take forward work on the key themes that came out of the Audit South West Survey.
[On PERIPrem] The event inspired me to become more involved in PERIPrem and embed the PERIPrem elements in other training delivered to both the medical and nursing team working with neonates. It was lovely to see so many individuals inspired to take ownership of this improvement project as a result of their attendance
Charlotte Bisset - Senior Neonatal Staff Nurse and Clinical Educator, North Devon District Hospital
