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HSJ Patient Safety Congress

This year’s programme is shaping up to be our strongest to date. We’ve had guidance from the Congress Advisory Board to ensure our content is refreshed, evidence-based, and challenging, with focus on topics that don’t always get enough attention. Every session is designed to equip you with tangible solutions and outcomes to your safety challenges. With 10 core themes, the event will address the most pertinent challenges affecting quality of care today as well as longstanding safety issues that have been magnified as result of covid-19. Bringing together national policy makers, frontline innovators, award-winning trusts and patient representatives, the programme content will provide a 360-degree view on the latest safety developments and innovations.

This programme is a living document which serves as an indication of the final programme content; therefore, details will change.

Day 1 – Thursday 15 September

8:00

Registration opens

8:50

Chair’s welcome and opening remarks

  • Set the scene for the Congress with an up-to-date overview of patient safety
     
  • Understand the major shifts in patient safety over the last year and what steps need to be taken to make further progress
     
  • Learn how you can make the most of the next two days to improve patient outcomes within your own organisation

Shaun Lintern, Chair, Patient Safety Congress and Health Editor, The Sunday Times 

9:00

NATIONAL UPDATE  

Opening keynote address 

A national update on the NHS Patient Safety Strategy: Where are we now? 

With Patient Safety Specialists and the first Patient Safety Commissioner for England now appointed, as well as new frameworks being rolled out, there is renewed impetus to put national priorities into practice at local level. Join Dr Aidan Fowler as he revisits the strategic aims of the NHS Patient Safety Strategy three years after its launch and get an update on where significant progress has been made, what areas require more momentum and how national priorities have shifted to get safety back on track

Dr Aidan Fowler, National Director of Patient Safety, NHS England & NHS Improvement and Deputy Chief Medical Officer at the Department of Health and Social Care 

 

9:20

Keynote panel
Why aren’t we learning from past mistakes? Breaking the cycle of repeat errors to advance the safety agenda

  • Identify long-standing barriers to change and discuss the underlying factors in healthcare that make it hard to implement key learnings and make real progress
     
  • Debate the effectiveness of national reports and enquiries
     
  • Re-thinking approaches to safety issues amidst increased system pressures – how can this be effectively tackled in a staffing crisis
     
  • Focusing on really understanding the problem before coming up with solutions to ensure long-term sustainability and safety 
     
  • Discuss practical ways you can break down barriers to improvement in your organisation

Professor Mary Dixon-Woods, Director and Professor of Healthcare Improvement Studies, THIS Institute and University of Cambridge

Professor Ted Baker, Former Chief Inspector of Hospitals, CQC

Tom Bell,  Organisational Culture and Ethics Consultant, Trainer, Author, Speaker, former NHS Manager, and Whistleblower 

Professor Sir Robert Francis QC, Chair, Healthwatch England

10:05

Keynote panel
Putting an end to gender bias in healthcare: Re-setting the dial on women’s health and safety 

  •  Hear from a female patient about her experience with surgical mesh and the challenges faced as a woman navigating the health system 
  • Consider the recurring theme from personal testimonials and healthcare scandals in recent years, that women’s voices and patient safety concerns are being ignored or dismissed 
  • Address the lack of transparency around the risks of medicines and medical devices
  • The need to discuss both benefits and risks of investigations and medication
  • Ending the culture of doctor knows best - Is there a clash of values between medical paternalism and patient autonomy? 

Yvette Greenway, Patient Representative 

Professor Matthew Cripps, Director of Behaviour Change, NHS England and NHS Improvement 

Professor Marian Knight, Professor of Maternal and Child Population Health, University of Oxford

10:45

Meet our Partners / Refreshment break

Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting 

Tea, coffee and refreshments available 

Outpatients’ department

Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions 

  Delegates can now break into the following 5 tracks and attend sessions which focus on hands-on learning and practical casestudies. Send your colleagues to different tracks to get the most out of the content 
   
Track 1 Track 2 Track 3 Track 4 Track 5

Building Restorative Organisations

Chaired by Professor 
Murray Anderson-Wallace,
Visiting Professor, Health Systems Innovation Lab London South Bank University

In association with Radar Healthcare

Human factors

Chaired by Martin Bromiley OBE, Founder, Clinical Human Factors Group and Professor Chris Frerk, Chair, Clinical Human Factors Group

In association with BD

Patient safety in non-acute settings

Chaired by Jyotika
Singh, 
Healthcare Consultant and Former Senior Pharmacist, Wilmington Healthcare

Patient and family engagement

Chaired by Rachel  Power, Chief Executive, The Patients Association

Supporting our workforce

Chaired by Annabelle Collins, Senior Correspondent, HSJ

11:30

Panel
Tackling bullying and harassment: What a restorative just culture looks like in practice  

  • Hear examples of how the lack of a just culture can lead to bullying, misperceptions, and an increase in patient safety errors 
  • Understand the difficulties of dealing with bullying from a leadership perspective 
  • Find out what a restorative just culture actually means, how to implement it and what it should look like in practice
  • Share successful strategies from trusts on how to manage and prevent the disproportionate impact of bullying on minority groups 

Joe Rafferty, Chief Executive, Mersey Care NHS Trust

 

Modelling what good looks like: An automation approach to addressing medication error 

  • Understand human factors that influence the collaboration between humans and automation 
  • Digital evolution and resistance to change: Understanding barriers to overcome, fully embrace and implement system automation 
  • Learn how automation can support clinical practice and deliver improved medication management  
  • Proof of concept Hear examples from trusts that have adopted connected Medication Management and how this has helped reduce errors, waste and increased efficiencies

In association with BD

Francine de 
Stoppelaar,
Director of 
Pharmacy, Cleveland 
Clinic

James Davis, Chief Innovation 
Officer, Royal Free 
London NHS FT

Nikki Smith, Patient 
Safety Lead for 
Medicines, NHS Surrey 
Heartlands CCG

Tim Kane, Consultant Orthopaedic Surgeon, Portsmouth NHS Trust and Director, Practical Patient Safety Solutions 

Restart a Heart: Optimising survival rates through rapid response to out-of-hospital cardiac arrests

  • Hear directly from doctor on how he and his team help save the life of an athlete who suffered a cardiac arrest  
  • Gain insight into the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 
  • Learn about a clinician-led quality improvement initiative around prompt CPR to improve patient outcomes 
  • Join a practical workshop on CPR training across the 2-day Congress to learn how to respond in lifethreating situations 

Dr Jonathan Tobin, GP and Club Doctor, Wigan Athletic Football Club

Dr Alison Tavaré, Clinical Lead, NHS@Home SW and Primary Care Clinical Lead, West of England Academic Health Science Network

Marisa Mason, Chief Executive, NCEPOD

Professor Andrew Lockey, President of Resuscitation Council UK 

Humanising harm: Using a restorative approach to heal and learn from adverse events

  • Explore how current investigative responses can increase harm for all those affected, by neglecting to respond to the human impacts
  • Understand how the risk of harm can be reduced if investigations respond to the need for healing alongside system learning (with the former having been consistently neglected)
  • Debate why incident responses should be conceived within a relational as well as regulatory framework and how this can radically shift the focus, conduct and outcomes of patient safety investigations
  • Identify the preconditions and mechanisms that enable the success of restorative approaches in global health systems

Joanne Hughes, Patient Advocate and Founder, Harmed Patients Alliance

Jo Wailling, Registered Nurse, Research Fellow and Facilitator with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, New Zealand (live stream)

Allison Kooijman, Patient Advocate, School of Nursing, University of British Columbia (live stream)

Looking behind the brave face: Getting in tune with your staff to achieve peak performance and embed psychological safety

  • Address mental health and impact on staff from a neuro-scientific perspective 
  • Deep dive into the different levels of brave face syndrome or presenteeism and identify behaviours you will see and how this impact staff’s ability to perform and do their job safely 
  • Looking at ‘why’ not ‘who’ during investigations and identifying the real underlying cause when things go wrong. Are staff capable of providing safe care in the brain state and environment they’re in? 
  • Gain practical ideas from trusts that have approached mental health like a risk assessment and the impact it’s had on teams so far  
  • Take back strategies you can embed in your organisation to ensure staff are working in a positive brain state

Maria Paviour, Occupational Neuropsychologist, Author and Founder of Wellbeing with Cari and the NeuChem Coaching Model

Ranjit Kirton, Workplace Behaviour Innovator,  The Behaviour Garage 

12:20

Time to move between sessions

12:25

Track 1

Building Restorative 
Organisations

Track 2

Human Factors

Track 3

Patient safety in non-acute settings

Track 4

Patient and family 
engagement

Track 5

Supporting our 
workforce

NATIONAL UPDATE NATIONAL UPDATE

Driving a culture of learning from patient safety incidents:  Making the switch from NRLS to LFPSE  

  • Hear about the transition from the current National Reporting and Learning System (NRLS) to Learn from Patient Safety Events (LFPSE)
  • When and why: Understand the reasons behind the change and how the new reporting system will benefit your teams and support national learning and improvement 
  • Find out how the system will work in practice to speed up incident data capture
  • Understand how to triangulate LFPSE with CQC, NICE, policy, and audit to provide local assurance and continuous improvement
  • Take away strategies you can implement to achieve quality insight and improve safety and compliance culture 

In association with InPhase

Marcos Faquer 
Manhaes,
 Head of LFPSE 
and NRLS, Patient Safety, 
NHS England and NHS
Improvement

Robert Hobbs, Chief Executive Officer, InPhase

Warren Edge, Senior 
Associate Director of 
Assurance & Compliance, 
County Durham and 
Darlington NHS FT 

A human factor approach to examining errors that contribute to death or serious harm  

  • Hear about Beth’s Story from Clare Bowen, mother of Bethany who died during routine surgery
  • How and why: Understand the multiple human factors and medical errors that lead to Bethany’s death
  • Hear perspectives from a trust CEO on what the death of a patient taught him about human factors
  • How to change defensive organisational behaviours, with emphasis on learning rather than denial
  • Share strategies and examples to ensure complete transparency and candour when things go wrong to achieve true restorative justice for families involved 
  • Take away strategies you can implement to reduce the incidence of similar errors 

Clare Bowen, Patient Representative and Trustee, Clinical Human Factors Group

Professor Joe Harrison, Chief Executive, Milton Keynes University Hospital NHS Foundation Trust

Casting a safety net between primary and secondary care: A digital approach to sustaining safety across the patient pathway  

  • Hear a patient’s perspective on the challenges and safety issues experienced as they moved between primary, acute and virtual care settings 
  • Assess the dynamic between secondary care leadership and primary care delivery and how this relationship can be fine-tuned to improve patient safety 
  • Hear from a digitally advanced organisations and find out how they use digital to support organisational strategy, not lead it 
  • Get a national update on the Digital Clinical Safety Strategy and how it will help protect patients using hybrid models of care

Jyot Mehan, Chief 
Executive, Health Care 
First Partnership

Dr Natasha Philips, Chief Nursing Information Officer, 
NHSX

Sheinaz Stansfield, Development Advisor,
Primary Care 
Transformation Team,
NHS England and NHS 
Improvement

What does true co-production look like? The impact of patient input and involvement on quality improvement

  • Hear how the involvement of patients helped challenge trusts to think differently about safety initiatives based on their own experience using the health service
  • Discuss and share approaches you can take to attract patient partners, and understand what training, support and conditions are required to enable meaningful co-production  
  • Hear successful examples from trusts that involved patient partners in QI projects and assess the positive impact on patient safety and staff experience
  • Key takeaways:  Take back strategies to help you involve patients as partners in your work to help shape and influence improvements in your organisation 

Charlotte McArdle, Deputy Chief Nursing Officer for Patient Safety and Improvement, NHS England and NHS Improvement

John Curtin, Patient Partner

Dr Anna Winfield, , Patient Safety & Quality Manager and Specialty Doctor in Elderly Medicine, Leeds Teaching Hospitals NHS Trust

Harnessing digital to join up systems and processes to facilitate real learning and improvement 

  • Discuss what good quality looks like and the challenges around ensuring organisations are getting the full picture of whether or not they are delivering good quality
  • How a siloed approach to learning from incidents and the use of multiple tools and systems makes its harder to identify trends and there for prevents learning 
  • Find out what solutions are available to help you join up different processes. Hear examples from a trust on how this has positively impacted safety outcomes in their organisation

In association with Radar Healthcare

Paul Cresswell, Associate Director of Quality Governance, North Bristol NHS Trust 

Molly Kent, Patient Safety Specialist, Radar Healthcare 

13:15

Lunch break in the Exhibition Hall

Meet our Partners
Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting 

Outpatients department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions 

Patient Safety Specialist Networking Lunch

Please note this lunch is invitation only and exclusively for Patient Safety Specialists.  

If you have received confirmation of your attendance for this networking lunch, please head to Exchange 1

14:15

Track 1

Building Restorative 
Organisations

Track 2

Human Factors

Track 3

Patient safety in non-acute settings

Track 4

Patient and family 
engagement

Track 5

Supporting our 
workforce

Are we losing sight of what good looks like? Reversing the impact of normalised deviance on patient safety

  • Explore the systematic conditions and flaws that set up good people to fail and the long-term effect this has on patient care when behaviours do not change 
  • The importance of a top-down approach, ensuring good practice is carried out and followed through by leaders to embed a strong safety culture across the entire organisation 
  • Discuss and share actions you can implement now to help identify and manage unsafe practices and behaviours before they become normalised and pose risks to patient safety, quality care, and employee morale 

Professor Rebecca Lawton, Professor in Psychology of Healthcare, University of Leeds and Director, NIHR Yorkshire and Humber Patient Safety Translational Research Centre 

Professor Matthew Cripps, Director of Behaviour Change, NHS England and NHS Improvement 

Ranjit Kirton, Workplace Behaviour Innovator,  The Behaviour Garage

Challenges and possibilities of integrating human factors and ergonomics into healthcare

  • Hear from experts on the current barriers and opportunities of bringing human factors into the health system
  • Discuss ways you can get past system and cultural issues to operationalise human factors thinking
  • Hear different perspectives on the system from each speaker, whilst also learning from their shared thinking to help you incorporate human factors in your organisation

In association with NHS Supply Chain 

Dr Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England and NHS Improvement

Professor Chris Frerk,  Chair, Clinical Human Factors Group

Professor Paul Bowie,  Programme Director (Safety & Improvement), NHS Education for Scotland

Colette Longstaffe, Product Assurance Specialist-Clinical and Product Assurance (CaPA), NHS Supply Chain 

Improving outcomes and experiences of patients discharged from mental health hospitals

  • Find out about a research study initiated by a patient who experienced difficulties when discharged due to no plan being put in place 
  • Hear how this coled study, involving three trusts, aims to improve outcomes for service users being discharged from mental health hospitals 
  • Gain insight into the factors and challenges that prevent mental health hospitals from providing a seamless discharge experience for patients
  • Learn how they plan to co-produce a new support package and toolkit for discharge using realist methods and systems engineering approaches to healthcare which can be applied and adapted to the discharge process 
  • Understand how this research has the potential to positively impact patient safety and patient experience

Sarah Rae, Patient Representative

Dr Jon Wilson, Consultant Psychiatrist, Norfolk and Suffolk NHS FT 

Professor John Clarkson, Professor of Engineering Design, University of Cambridge and Professor of Healthcare Systems, Delft University of Technology

Positive family engagement and involving families well: Impact on the system and patient safety

The Making Families Count session will focus on the importance of positive family engagement including: 

  • Using positive family engagement after a patient safety incident 
  • How to have difficult conversations with families and do this well 
  • Using Confidentiality and Duty of Candour with families 
  • What does a blame-free culture look like and how does it benefit families and staff?

Rosi Reed, Training Coordinator, Making Families Count

Frank Mullane MBE, Member, Making Families Count

Stephen Habgood, Director, Making Families Count

Interactive Workshop

Tackling discrimination and inequality in healthcare   

We know that inclusive workplaces are crucial for both staff wellbeing and for patient safety.  So why are so many still experiencing discrimination and what can we do to change it?  

In this interactive session we will: 

  • Reflect on the impact of discrimination in healthcare   
  • Consider how cultures aid discrimination at work 
  • Explore the work the GMC is doing to tackle inequality issues 
  • Identify what you can do locally to create a more inclusive culture, including resources and support available to you   

In association with the GMC

Chris Lawlor, Senior Regional Liaison Advisor, Outreach Development Support Unit, General Medical Council

Victoria Goodwin, Regional Liasion Advisor – East Midlands, General Medical Council 

15:05

Time to move between sessions

15:10

Track 1

Building Restorative 
Organisations

Track 2

Human Factors

Track 3

Patient safety in non-acute settings

Track 4

Patient and family 
engagement

Track 5

Supporting our 
workforce

Panel
Balancing no-blame with accountability:  Playing your part by speaking up to create a health system that owns up to error 

  • Address issues around blame and defensiveness as key contributors to the lack of safety progression over the past decades
  • Debate why defensiveness remains a core issue within the system and understand what factors are preventing a shift in culture, at both national and local level
  • Practical, initial strategies for leaders to build a psychologically safe environment, that encourages transparency and honesty amongst staff
  • Responding to error: Learn how you can create a just culture where you ensure staff are speaking up when things go wrong without blame or fear of reprisal  
  • Understand the impact this will have on patient safety through the prevention of repeat errors

Jasvinder Sohal, Chief People Officer, Bath & North East Somerset, Swindon and Wiltshire ICS and Former Chief People Officer, Solent NHS Trust 

John Walsh, OD Lead / Freedom To Speak Up Guardian, Leeds Community Healthcare NHS Trust

Tom Bell, Organisational Culture and Ethics Consultant, Trainer, Author, Speaker, former NHS Manager, and Whistleblower

Being proactive to uncover unknown risks and reduce never events

  • Learn about a common never event involving a nasogastric tube and why it is also a national issue
  • Hear about the post-incident investigation process which resulted in no findings of care gaps or staff errors
  • The importance of being proactive and inquisitive and how this resulted in identifying previously unknown gaps
  • Learn how one trust is evaluating all PH strips on the market in order to adopt the best device and minimise error
  • How this work has resulted in new guidelines that openly acknowledge the gaps in the system with the aim of preventing incidents

Karl Emms, Lead Nurse for Patient Safety, Birmingham Women’s and  Children’s NHS FT

Fiona Terry, Neonatal Matron, Joint Project Lead, Birmingham Women’s and  Children’s NHS FT

Jennifer Abbott, Clinical Educator, Birmingham Women’s and Children’s NHS F

Michelle Moseley, Senior Specialist Nurse, Birmingham Women’s and Children’s NHS FT 

Panel
Achieving true integration: Valuable lessons from mature integrated care systems outside England  

  • The key challenges faced in the establishment of systems-level care through the lenses of finance, workforce and operational delivery
  • Take a closer look at the Scottish and Welsh integrated care models and explore specific lessons you can take away from their approaches to partnership working  
  • How advanced levels of integration significantly enhanced patient safety, especially against the backdrop of covid19
  • Find out what initial challenges these systems faced when starting their integration journey, as well as key elements required for ICSs to succeed
  • How to best measure and assure patient safety when designing, implementing and refining acre pathways at systems level 

In association with RLDatix

Dr Chris Grant, Executive Medical Director, North West Ambulance Service NHS Trust

Darren Kilroy,  Medical Director, International, RLDatix

Dr Susan Gilby,  Chief Executive, The Countess of Chester Hospital NHS FT

Assessing quality of care in the home: Ensuring patients and families have the tools to safely self-manage  

  • How covid-19 has challenged percep tions around what patients can or should do – causing a major shift towards selfmanagement at home 
  • Assess the situational variables that could present risks to patients 
  • Understand the type of training and resources required for patients, families and clinicians to effectively identify and prevent potential risks in the home 
  • Hear examples of tools and training available that enhance safety in the home 

Jono Broad, Senior 
Manager Personalised 
Care, NHS England SW

Matthew Riley, Service User Representative

Navigating the dual challenge of prioritising quality initiatives with an already-stretched workforce

  • Understand the difficulties systems have in trying to drive evidencebased practice initiatives whilst coping with the service disruption and low staffing levels
  • How covid-19 further adds to this challenge, resulting in a ‘start and stop’ approach to QI, impacting staff’s commitment and engagement with improvement programs 
  • Hear best practice examples on how you can prevent staff burnout, to ensure your workforce have the capacity and energy required to engage with these programme 
  • Take back strategies and tips on how you can prepare your teams to reposition QI and accelerate innovation to improve patient outcomes

In association with Wolters Kluwer  

Rachel Dicker, Product Management Associate Director, Wolters Kluwer, Health, Learning, Research and Practice 

16:00

Meet our Partners  

Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting

Tea, coffee and refreshments available  

Outpatients department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions 

  Regroup with all attendees for the closing keynotes followed by the networking reception  
16:30 

The James Reason Lecture
Planning for the unthinkable: Responding to catastrophe in a healthcare setting

  • Hear from Professor Lucy Easthope, the UK’s leading authority on disaster management and recovery
  • Get a look behind the scenes at some of Lucy’s work on major disasters, including 9/11, the 7/7 bombings, the Indian Ocean tsunami and covid-19
  • Find out how healthcare systems should plan for disasters and the aftermath, prioritising emergency planning, compassion and putting those affected at the heart of arrangements
  • Assess why and how things go wrong in disaster management and what you can do to prevent repeat errors
  • Key considerations and takeaways: Short-term and long-term actions you can implement at local level

Professor Lucy Easthope, UK Leading’s Authority on Recovering from Disaster, Professor in Practice of Risk and Hazard, University of Durham and Fellow in Mass Fatalities and Pandemics at the Centre for Death and Society, University of Bath

17:10 - 18.00

End of day 1 - Networking drinks reception in the Exhibition Hall

After full day of discussions, debates, and learning, end your day by having a drink with colleagues and new acquaintances and get ready for the Awards celebration later in the evening! 

Please take time to give your feedback via the app

 

Day 2 – Friday 16 September

8:45

Chair’s welcome and opening remarks

  • Reflect on the key learning points from yesterday’s sessions

  • Look ahead to today’s topics

  • Find out the winner of the Patient Safety Congress poster competition

Shaun Lintern, Chair, Patient Safety Congress and Health Editor, The Sunday Times 

9:00 NATIONAL UPDATE  

Opening keynote address  

The first Patient Safety Commissioner for England: Putting the needs of patients first   

Join us as we welcome England’s first Patient Safety Commissioner, Dr Henrietta Hughes, who will share key priorities in her new capacity, as well as next steps and what to expect over the next few months.

  • Find out what steps have been taken so far to promote the safety of patients in the context of the use of medicines and medical devices  
     
  • Gain insight into the areas and issues around which the healthcare system will be challenged to ensure the safety of patients and the public  
     
  • Learn how Henrietta will set an example of integrity and ethical leadership – understand how this new role will change the perception of patient safety and truly help represent the views of patients and families 

Dr Henrietta Hughes OBE,  Patient Safety Commissioner, Department of Health and Social Care 

9:15

Keynote

Investing in the future: Challenges, opportunities and hope – A three year forward view of the health system  

Join Health Foundation Chief Executive, Dr Jennifer Dixon, as she shares her expertise and insights into what will help guide the health system towards its next stage of progress.  

  • Analyse the current trends in health, including health inequalities, demand for care, funding, digital and workforce capacity 

  • Get an update on system reforms and performance and current challenges around mitigating safety risks whilst clearing the elective backlog 

  • Find out what this means for safety as the NHS evolves

  • What you can do to play a part in helping create an environment that drives innovation and improvements in care 

Jennifer Dixon, Chief Executive, The Health Foundation

  Delegates can now break into the following 5 tracks and attend sessions which focus on hands-on learning and practical casestudies. Send your colleagues to different tracks to get the most out of the content 
 
Track 1 Track 2 Track 3 Track 4 Track 5

Governance and regulation

Chaired by Rosi Reed,
Training Coordinator,
Making Families Count

Clinician-led innovation

Chaired by Rachel 
Power,

Chief Executive, The 
Patients Association

Safety for vulnerable people

Chaired by Annabelle Collins, Senior Correspondent, HSJ

The deteriorating 
patient

Chaired by Lesley 
Durham,
President, International Society for Rapid Response Systems(iSRRS)

 

Women’s healthcare

Chaired by Susanna Stanford, Patient Safety Advocate 

9:35

NATIONAL UPDATE

Patient  Safety Incident Response Framework: What good looks like when learning and responding to patient safety incidents 

  • Learn about the new Patient Safety Incident Response Framework (PSIRF)
  • Understand the importance of overseeing system structures and processes to drive the right behaviours 
  • Hear from early adopters of PSIRF and gain insight specific learnings from the pilot  
  • Get advice from early adopters on how best to prepare for the implementation of PSIRF in your organisation 

Dr Lauren Morgan, Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford

Donna Forsyth, Director, Patient Safety Science

Tracey Herlihey,  Head of Patient Safety Incident Response Policy,  NHS England and NHS Improvement

Unleashing local 
innovation: Transforming emergency care delivery through collaboration between services 

  • Address the issues around managing ambulance delays and patient access to emergency care, resulting in harm or death 
  • Learn about the award-winning Remote Emergency Access Coordination Hub (REACH) and its innovative approach to delivering emergency care using virtual consulting rooms
  • Hear from a patient representative on their previous care experience versus their experience using REACH
  • Look at what the data shows and the impact the new model has had on patient experience and safety by reducing the number of ambulances conveyed to hospitals and patient walk-ins
  • Learn how this work in being rolled at scale and pace and share strategies of how you can implement similar solutions

Joanna Moore, Senior Improvement Advisor, Barts Health NHS Trust

Tony Joy, Lead Consultant for REACH and the Physician Response Unit, Barts Health NHS Trust

Tiffany Wishart, Senior Sector Clinical Lead, London Ambulance Service

 

Managing the effects of Long-covid on staff to prevent human error

  • Hear from frontline staff affected by Longcovid and get an understanding of how it is impacting their ability to carry out daily roles safely
  • Share practical steps managers can take to effectively support staff experiencing symptoms of Long-covid  
  • Recommendations and examples of how the current approach to longcovid can be improved to avoid harm and deterioration

Professor Amitava 
Banerjee,
 Professor of Clinical Data Science and Honorary Consultant Cardiologist  Institute of Health Informatics, University College London 

Dr Alison Twycross, Chair, Long Covid Nurses and Midwives UK and Member, Long Covid Support Employment Group (pre-recorded)  

 

Listening to families’ Call 4 Concern to prevent patient deterioration and avoidable deaths   

  • Hear from patient representatives whose concerns were ignored, leading to rapid deterioration and suicide
  • Taking family concerns more seriously as those who know the patient best
  • Learn how the Call 4 Concern initiative provides patients and families with more choice about who to consult about their care and facilitates the early recognition of patient deterioration

Dr Chris Subbe, Consultant Physician working in Acute Medicine, Betsi Cadwaladr University Health Board

Lisa Cornell and Kirsty Datson, Senior Critical Care Outreach Practitioners, Kettering General Hospital NHS FT  

Tackling Gaps in Patient Safety in Maternity: Embedding a Learning Culture

  • Gain insight into the findings from the Baby Lifeline ‘Mind the Gap’ report
  • Are we training the frontline in themes that relate to avoidable harm?
  • Hear how NHS Resolution is working to overcome barriers to a learning culture 
  • Explore the barriers and opportunities to improve maternity safety with staff on the front line 

In association with NHS Resolution

Dr Denise Chaffer, Director of Safety and Learning, NHS Resolution 

Sara Ledger, Head of Research and Development, Baby Lifeline

Victoria Vallance, Director of Secondary and Specialist Care, CQC 

10:25

Meet our Partners  

Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting 

Tea, coffee and refreshments available 

Outpatients’ department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions 

11:15

Track 1

Governance and 
regulation

Track 2

Clinician-led 
innovation

Track 3

Safety for vulnerable 
people

Track 4

The deteriorating 
patient

Track 5

Women’s healthcare

Is anybody ‘Learning from Deaths’? – Implementing safety improvements based on a review of the national LFD Programme

  • Analysis of national statutory reporting within the NHS in England 2017- 2020
  • Understanding what ‘Learning’ and ‘Actions’ have occurred
  • A review of how trusts have assessed the impact of their actions
  • Hear examples of how trusts are engaging with and involving families in their LfDs work
  • Recommendation s for how the LfDs programme can be developed and implemented further and what this means for your organisation

Dr Zoe Brummell, Anaesthetic and Intensive Care Medicine Specialist, University College London Hospitals NHS Foundation Trust

Dorit Braun , Patient Representative

Dr Emma Rowland, A&E Consultant, Homerton University Hospital NHS Foundation Trust

Panel
The creation of the Patient Safety Managers Network: Set up by staff, for staff to help spread safety innovation

  • Learn about the fast-growing Patient Safety Managers Network, set up by staff, and the motivation behind it
  • Understand how members of the network are working to break down barriers to improvement by sharing best practice between trusts
  • Discuss the impact of communicating with peers in similar roles regarding patient safety challenges and innovation
  • Find out what the network has achieved so far and how it supports the implementation of best practice across 82 different trusts
  • Assess the impact of the network on patient safety so far and future plans to continue sharing learning

Claire Cox, Patient Safety Lead, King’s College Hospital NHS Foundation Trust

Jordan Nicholls, 
Serious Incident, 
Governance and Quality Improvement 
Lead, Central and 
North West London 
NHS Foundation Trust

Jayne Addison, Deputy Head of Quality Governance, Patient Safety and Risk, Wythenshawe Hospital, Manchester University NHS Foundation Trust

Chaired by Helen Hughes, Chief Executive, Patient Safety Learning

Reducing health inequalities for people with learning disabilities: Looking beyond the disability to improve safety

  • Recognise the dangers of diagnostic overshadowing with LD patients and hear examples of avoidable patient harm caused as a result
  • Find out what you can do to prevent diagnostic overshadowing – hear about the RCP Acute Care toolkit for people with learning disabilities
  • Take back practical, reasonable adjustments you can make in your organisation to enhance safety for patients
  • Learn about how addressing inequalities can be embedded as a golden thread to help drive improvement”

Scott Riley, South West Inclusion Health Lead, NHS England and NHS Improvement (South West)

Hilary Gardener, Strategic Liaison Nurse for Adults with Learning Disabilities - Primary Health, Hertfordshire County Council

Gavin Howcraft, Expert by experience

Chaired by Dr Alison Tavaré, Clinical Lead, NHS@Home SW and Primary Care Clinical Lead, West of England Academic Health Science Network

Bridging the gap between mental and physical health deterioration in acute hospital settings

  • Assess why coexisting mental health problems of patients admitted to acute hospitals with a physical ailment are often overlooked 
  • Learn what psychiatric interventions are required to assess and manage patients as well as multidisciplinary discharge planning 
  • How you can fully integrate Liaison Psychiatry into your organisation and the impact this will have the patient safety 
  • Get an update on national approaches towards record sharing, and better staff training to recognise mental health issues  

Matthew Riley,  Service User Representative 

The systematic dismissal of women’s safety concerns and its contribution to avoidable harm

  • Hear from patients who were not informed of the risks of taking sodium valproate and the harm it has caused to them and their families
  • Ending the culture of doctor knows best - Discuss why concerns raised by female patients are still being dismissed as ‘women’s problems’, leading to avoidable harm 
  • Find out what changes are taking place at national level to strengthen regulation around sodium valproate and ensure risks are communicated properly 
  • Learn from successful case studies on how to ensure full transparency when preparing women and girls of potential risks in an ethical and responsible way

Emma Murphy, Founder, Independent Fetal Anti-Convulsant Trust (IN-FACT) 

Janet Williams, Founder, Independent Fetal Anti Convulsant Trust (IN-FACT)

12:05

Lunch break in exhibition Hall

Meet our Partners  
Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting

Outpatients department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions 

13:00

NATIONAL UPDATE

Keynote
The road to zero: Eliminating unnecessary deaths in a post-pandemic NHS

  • Hear from The Rt Hon Jeremy Hunt MP on how the NHS can reduce the number of avoidable deaths to zero, saving money, reducing backlogs and improving work conditions in the process

  • What is being done at national level to help make the switch from a culture of blame to a culture of learning in order to meet this goal

  • Key considerations and takeaways to help you deliver the safest, highest quality care post-pandemic to achieve our own 1948 moment

  • Take this opportunity to ask questions and challenge our speakers via the event app

The Rt Hon Jeremy Hunt MP, Chair, Health and Social Care Committee and Former Health Secretary 

13:30 Time to move between sessions 
13:40

Track 1 

Governance and 
regulation

Track 2

Clinician-led 
innovation

Track 3

Safety for vulnerable 
people

Track 4

The deteriorating 
patient

Track 5

Women’s healthcare

NATIONAL UPDATE

Minimising the risks of extravasation: A national update on new guidelines

  • Understand the volume of claims submitted relating to extravasation injury and the cost this has on patients and the system 
  • Hear from a trust that has implemented innovate ways to reduce the risk of extravasation injury
  • Get an update on national guidance and recommendations 

Andrew Barton, Nurse Consultant, Vascular Access & IV Therapy, Frimley Health NHS FT and Chair, National Infusion and Vascular Access Society (NIVAS)

Samantha Thomas, Associate Safety and Learning Lead, NHS Resolution  

Chaired by Helen 
Hughes
, Chief Executive, 
Patient Safety Learning

Panel
Taking the next step in your improvement journey: Learning from organisations that ‘require improvement’  

  • Hear from trusts in different stages of their quality improvement journey and find out which areas they are prioritising to raise quality standards  
  • Hear examples of inspirational projects from trusts that helped bridge the gap from ‘requires improvement’ to ‘good’   
  • Take back practical and relatable advice to help you in your own improvement journey

Hayley Flavell, Director of Nursing, Shrewsbury and Telford Hospital NHS Trust 

Dr Ruth O’Dowd, Consultant Anaesthetist and Associate Medical Director Patient Safety and Quality Improvement, North Cumbria Integrated Care NHS FT 

Michael Wright, Programme Director, Maternity Assurance, Shrewsbury and Telford Hospital NHS Trust 

Ben Davies, Head of Clinical Quality & Professional Practice at Nuffield Health 

Chaired by Dr Lauren Morgan, Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford

Thinking pragmatically about capacity: Innovative approaches to improving hospital flow for urgent care 

  • Address the need to change and expand the general thinking around emergency patient flow
  • Explore the barriers and enablers to flow improvement 
  • Consider the links between system safety, quality and hospital flow
  • Get involved in design thinking and find out about innovative approaches to flow improvement
  • Take back practical tools for a fresh look at flow within your own setting

Phil Wilson,  Head of Nursing, Birmingham Women's and Children's NHS FT 

Equipping staff with the skills to detect the seriously ill and deteriorating woman

  • Address the challenges of recognising impending maternal collapse, especially with little or no warning signs of severe maternal illness  
  • Learn about the Maternity Early Obstetric Warning Scoring System (MEOWS), designed to help critical care staff  identify early warning signs for maternal collapse
  • Hear about the impact of these guidelines in practice, leading to appropriate escalation and intervention, improving women’s safety outcomes 
  • Share and take away maternity enhanced care competencies which provide you with skills to effectively assess and manage pregnant and postnatal women 

Eddie Morris, President, Royal College of Obstetricians and Gynaecologists

Justin Chu, Consultant Obstetrician and Gynaecologist Sub-specialist in Reproductive Medicine and Surgery, Birmingham Women’s and Children’s NHS FT 

NATIONAL UPDATE

The first Women’s Health Strategy: Redesigning the system to prioritise care on clinical need, not gender

  • Learn about the government-led Women’s Health Strategy in England as part of plans to level up health care
  • Get an update on key issues raised in response to a call for evidence to inform the government’s approach to tackling gender health inequality
  • Find out how these insights will inform the upcoming Women’s Health Strategy to create a healthcare system that prioritises care on the basis of clinical need, not gender

Professor Matthew Cripps, Director of Behaviour Change, NHS England and NHS Improvement 

14:30

Time to move between sessions

14:35

Track 1 

Governance and 
regulation

Track 2

Clinician-led 
innovation

Track 3

Safety for vulnerable 
people

Track 4

The deteriorating 
patient

Track 5 

Women’s healthcare

NATIONAL UPDATE

Interactive session
HSIB’s Investigation Education Programme: A systems approach to local safety investigations 

  • Learn about HSIB’s Investigation Education Programme and get a snapshot of the type of training and modules you can  benefit from 
  • Hear about the transition and future directions of the new HSSIB as it transitions into a statutory body in 2023  
  • Take back a practical overview of the importance of human factors and systems thinking in investigations 
  • Next steps for you and your teams to get involved and benefit from this free training opportunity

Professor Paul Bowie, Senior Investigation Science Educator, Healthcare Safety Investigation Branch (HSIB) 

Dr Laura Pickup, Senior Investigation Science Educator, Healthcare Safety Investigation Branch (HSIB)

Andrew Murphy Pittock, Head of Investigation Education, Healthcare Safety Investigation Branch (HSIB) 

 

Panel

An update from Patient Safety Specialists: Assessing the current barriers and drivers to an ingrained safety culture

  • Get an update from Patient Safety Specialists on the impact of this new role so far on safety, culture and quality 
  • Find out how the aim of creating an ingrained safety culture across each organisation has varied across different trusts and the barriers/enablers behind this  
  • Learn how you can support   Patient Safety Specialists to ensure the whole organisation is involved in the safety agenda

Elizabeth Klein, Patient Safety Specialist and Head of Nursing Patient Safety and Clinical Quality, North Cumbria Integrated Care NHS FT 

Linnie Pontin, Patient Safety Specialist and Head of Quality and Patient Safety, Homerton Healthcare NHS FT 

 

Powering traceability and transparency in a clinical setting: Using digital to get at the forefront of patient and product management

  • Find out how the adoption of GS1 standards is improving efficiencies and preventing unnecessary patient harm across the NHS 
  • Learn about a pioneering digital project, Scan4Safety which uses barcode technology to enable effective patient and product management 
  • Hear examples from trusts that are using Scan4Safety and find out the impact on patients and staff so far
  • Discover how you can get started on your own GS1 standards adoption journey and engage with those leading the charge in implementing Scan4Safety 

In association with GS1  

Steve Bush, Medical Director Operations, Leeds Teaching Hospitals Trust

Sarada ChunduriShoesmith, Associate Director at National Institute of Health and Care Excellence London  

 

The Critical Care Outreach Practitioner Framework: A National Standardised Credential 

This session will present the rational, development and content overview of the Critical Care Outreach Practitioner Framework 

  • Understand the rational and need to develop a National educational framework and standardised credential for Critical Care Outreach Practitioners 
  • Look at the practice levels and framework content and competencies 
  • Find out how the standardised credential will be delivered 

 

Lesley Durham, President, International Society  for Rapid Response Systems (iSRRS)

Tackling racial disparities in women’s health  

  • Get a thorough understanding of the health disparities faced by Black, Asian, and minority ethnic women, including receiving poor quality of care and health outcomes, with higher rates of morbidity and mortality 
  • Explore what is being done on the ground to narrow the inequalities gap and improve diagnosis, early interventions, and treatment for women 
  • Look at learning from successful case studies and how these can be applied across different care pathways 

Dr Karen Joash, Consultant in Obstetrics and Gynaecology, Imperial College  Healthcare NHS Trust and Head of School for Obstetrics and Gynaecology, Health Education England

Cecily Henry, Patient and Public Involvement Lead, Loughborough University 

 

15:20 Regroup with all attendees for the closing Q&A plenary session  
15:30

Q&A Panel 

Patient Safety Question Time

Don’t miss out on the closing Q&A quickfire discussion with some of the most leading figures in healthcare! This is an opportunity for you to quiz and challenge our panel of patient safety experts. Send in your questions and comments live via the event app and find out the most common concerns amongst our audience - all to be addressed! 

Charlotte McArdle, Deputy Chief Nursing Officer for Patient Safety and Improvement, NHS England and NHS Improvement 

Dr Habib Naqvi MBE, Director, NHS Race and Health Observatory

Professor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University

Rob Behrens, Parliamentary and Health Service Ombudsman

Jono Broad, Senior Manager for Co-Production and Patient Experience, Lead for the Integrated Personalised Care Team, South West Regional Team, NHS England and NHS Improvement 

16:30

Chair’s closing remarks

Shaun Lintern, Chair, Patient Safety Congress and Health Editor, The Sunday Times   

Please take time to give your feedback via the app

 

 

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