Share and Learn

IHPN’s Share and Learn Community of Practice provides member organisations with the opportunity to share and learn from incidents, complaints and actual or possible emerging concerns pertaining to patient safety and quality in a safe and confidential space. It is now in its third year and continues to mature its approach. For example, case studies shared in 2024 are beginning to highlight a shift in how organisations respond to patient safety incidents, with an increasing focus on understanding how and why incidents occur and the contributing factors.

Key themes emerging this year include the importance of encouraging staff to take a “time out” moment, fostering an open culture that allows colleagues to debrief safely, and sharing best practices across organisations. Scenario training has also proven vital in helping staff understand the value and limitations of national clinical guidelines. Other critical areas of focus include recognising the positive impact of the involvement of families and loved ones, ensuring the availability and proper maintenance of medical devices, and addressing the challenges posed by high cognitive load on staff. This includes managing multiple priorities, challenging environments, unscheduled tasks, workload unpredictability, and time pressures, particularly as a higher number of incidents were observed toward the end of staff shifts.

Case study

The Berkshire, Oxfordshire & Buckinghamshire Shared Learning Network (BOBSLN), initiated by Ramsay Health Care’s Berkshire Independent Hospital (BIH) in response to critical patient safety incidents, has transformed healthcare collaboration among seven local providers. Established to foster open discussions on patient safety and clinical incidents, BOBSLN promotes a culture of shared learning, significantly improving communication and response times to safety concerns.

Through bi-monthly meetings and the integration of patient feedback, the network has driven innovative practices, such as a pre-operative risk assessment for post-operative Hyponatraemia, resulting in a marked reduction in incidents. Endorsed by the CQC as Outstanding Practice, BOBSLN exemplifies the power of collaboration in enhancing patient care quality and operational efficiency across the healthcare landscape.