Winner: Salford Royal foundation trust
Shortcomings in the early detection of cancer were tackled and the process expanded to other forms of the disease
The trust's risk management systems showed that the lengthy series of events following a clinician's request for a radiology investigation meant there was no guarantee that images reported as suspicious would be seen by that clinician. A diagnosis of malignancy could be missed or delayed.
A multidisciplinary group went on to develop and introduce a system to ensure that every chest x-ray report showing suspicions of early cancer would be seen by an appropriate clinician and receive effective follow-up. Twelve months after the system was introduced, an audit identified 21 patients whose diagnosis would have been missed or delayed otherwise.
The process was considered so effective, the safety net policy was further developed to cover all findings where cancer was suspected. The radiologist indicates a trigger phrase, "code red flag", on a report when new unexpected cancer is suspected and gives it top priority on the electronic reporting systems.
Cellular pathology has now adopted the safety net for reporting unexpected malignancies. This cost-neutral system is proven to save lives. It is not dependent on any person or department and has been embedded into practice in a short time.
The judges praised the project for looking at a serious incident, learning from it and instilling significant change across the organisation. They described the work as heart-warming, innovative, evidence-based, transferable and inspiring.
They also congratulated Salford on an excellent presentation, saying it really brought the patient into the room.
SRFT risk management systems, contact firstname.lastname@example.org
Highly Commended: NHS Tayside and NHS Forth Valley
A pilot project over two years has been exploring how to develop and implement patient safety and risk management in primary care.
Participating general practices were given training, tools and support to test and implement sustainable improvements, including incident reporting, risk registers and medication projects.
From early in the project, practices have sought to inform patients of patient safety work and develop this communication into involvement. All practices developed risk registers and a review system, as well as completing projects to reduce repeat prescribing risks. Incident reporting systems were found to be inadequate and practices have been trying alternatives.
Implementing patient safety and risk management in primary care, contact email@example.com
Highly Commended: Skills for Health - Workforce Projects Team
Established as a modest pilot five years ago, the Hospital at Night programme now operates across the UK and is receiving international interest and recognition. Its fundamental principles are about safer care and safer training.
The evolving model of care - now extending from the night shift into evenings, weekends and around-the-clock care - is seen as both a whole-systems safety solution and a way of integrating teams to work and meet patient needs in a focused manner.
Many NHS organisations where Hospital at Night has been implemented report a drop in the severity of clinical incidents at night and out of hours.
Hospital at night, contact firstname.lastname@example.org
Finalist: Birmingham and Solihull Mental Health foundation trust
In 2006 a comprehensive systems and practices review at The Bridge substance misuse service set patient safety as the priority for all its clients (almost 400). The service sought to achieve its objective - no preventable deaths from overdose - by identifying where risk of overdose could be reduced, linking with other agencies and implementing evidence-based initiatives to prevent major health risks.
Patient education, health examinations, audits and overdose management training have contributed to reductions in overdose deaths, as well as treatment for many patients with previously undiagnosed life-threatening medical conditions.
Preventing overdose and death among heroin addicts, contact email@example.com
Finalist: Cambridge University Hospitals foundation trust
The foundation's Central Venous Access team ensures patient safety by reducing line-associated bloodstream infections. It is the only trust in the country with a dedicated theatre suite for both inpatients and outpatients who require central venous access lines for treatment.
The nurse-led and multidisciplinary CVA service is dedicated to inserting and maintaining central venous lines and providing after-care. The service has made an important contribution to patient care and the reduction of CVA-associated bloodstream infections; it has also saved money.
Central venous access service, contact firstname.lastname@example.org
Finalist: Luton and Dunstable Hospital foundation trust
Accelerate Patient Safety is a three-year programme that focuses on releasing frontline staff to lead improvement while strengthening leadership and a culture of patient safety. It has several aims: to build capability and expertise for continuous improvement; to strengthen the leadership of the safety culture; and to give senior clinical staff across the organisation the time to lead improvement teams to embed that culture. Over the next three years, the trust will strive to demonstrate measurable improvement and share its learning across the NHS and beyond.
Accelerate patient safety, contact email@example.com
Finalist: NHS Purchasing and Supply Agency
The Purchasing for Safety project was run as a pilot study in conjunction with three NHS trusts and set out to demonstrate the role procurement could play in reducing risk in the processes associated with injectable medicines.
The project highlighted a set of risk-reduction strategies where approaches to procurement can positively impact on patient safety. A wealth of evidence has been gathered to support local, regional and national action. Recommendations for a Purchasing for Safety framework have been drawn up and are being translated into objectives.
Purchasing for safety, contact firstname.lastname@example.org