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Is the health environment putting your patients at risk?

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A range of hazards can jeopardise patient safety. Alison Whyte looks at risks in the physical environment.

Patient safety is a key priority in the NHS. Whether this is due to increased media interest or more vocal patient groups, healthcare professionals and providers are thinking harder about the issue. And nurses need look no further than their working environment to find plenty of hazards.

The positioning of furniture, such as chairs, lockers and bedside tables around patient beds, are common trip hazards, as are the leads that trail from electrical equipment.

Deborah Turnbull, ward manager at City Hospitals Sunderland NHS Foundation Trust trauma admissions unit, says these factors are minimised, not just through regular health and safety checks but because staff do a weekly environmental audit. As well as checking that beds are free of obstructions, this includes ensuring sinks are not blocked and that hot-water and handwashing signs are clearly displayed.

‘I ask different grades to do it each week so that everyone becomes practised at looking out for the key issues to do with patient safety on the ward,’ she says.

Ms Turnbull also encourages patients to report any safety concerns they have directly to her. ‘They see me on four rounds a day, so there is ample opportunity for them to bring issues up,’ she says.

However, solutions are less simple when problems are related to structural issues around the hospital building. One of the key structural factors affecting patient safety at Ms Turnbull’s hospital is the location of side rooms on some wards. She explains that, particularly when staff numbers are low, it is much harder to attend to patients who are located farther away.

‘On a trauma ward, it’s so important that side rooms are nearby because we have patients who are delirious, have infections and are generally very poorly. The location of these rooms on my current ward is fine but on my last ward, it was dreadful.’

Many problems that arise in hospitals can be put down to the age of the buildings – there are still plenty of hospitals built and designed for a different era and a set of patients with vastly different needs. So when hospitals are built from scratch today, they are designed from a whole new perspective with modern patient safety standards at their core.

For Pat Young, design lead at the National Patient Safety Agency, one key area when it comes to minimising risk is how the structural space is arranged. She says: ‘Rather than having a single nurse station, it’s better to have smaller stations dispersed among the patients. This way, nursing activities happen closer to the patient and there’s less likelihood of things going wrong. It’s also better for observations.’

Ms Turnbull agrees. ‘I can see the advantage of more stations. The problem here is that we have 36 beds so there’s quite a distance between the nurse station and the patients.’

According to Frances Healey, patient safety manager at the NPSA, safety is all about how patients interact with their environment. For example, she says, a patterned carpet would appear to pose no risk to the vast majority of patients but to someone with dementia, certain patterns can appear like steps. ‘It’s all about how they interpret what they see.’

She adds that something as simple as light gradients could pose a risk to older patients. ‘If someone walks out of a brightly lit toilet at night and back on to a dimly lit ward, it could easily cause them to have an accident,’ she explains.

Out in the community, environmental factors also pose considerable risk to patient safety. Christine Pigford, falls coordinator at Sunderland Teaching PCT, says these can range from dangers in patients’ own homes in the form of rugs, worn carpets and stairs, to the street where uneven pavements, ungritted roads and unswept pathways can cause harm.

Although there is a limit to how much staff can do beyond people’s homes, staff at Sunderland Teaching PCT have just helped to produce a home safety checklist (see box) for clients, which nurses share with therapists, GPs and the local home improvement service.

‘As well as producing the checklist, last year we managed to put on training for all nurses working in the community to educate them about the environmental issues which affect patient safety, so awareness is now much higher,’ Ms Pigford says.

And this is clearly one of several nurse-led patient safety initiatives. At the Patient Safety Congress in May, Sarah Andrews, director of nursing, Eastern and Coastal Kent PCT, will describe how her PCT set up a committee involving care homes, social services, local hospital trusts, the ambulance service and GP practices, with agreed benchmarked standards throughout.

She says: ‘In the community, nurses are at the heart of patient safety, whether in the patient’s home, a care home, GP practice, health centre or school.’

Linda Watterson, who is programme manager of evaluating and improving at the RCN, agrees that nurses ‘hold the ring’ on information about patient safety. ‘They are absolutely central’, she says. ‘Information needs to be passed on during transfers, and some of it is critical to safe care. If you are becoming aware of a situation that isn’t safe, you need to share it.’

Nurses are excellent reporters but Ms Watterson believes more could be done to inform them of the outcome of reported matters. ‘Nurses sometimes feel they don’t hear about what happens in response to their report. It’s good if they can think: “I raised that issue and I know that something has been done about it”. Feedback is a crucial part of the loop.’

She says the emphasis is now on taking a proactive stance on preventing harm. ‘We are learning from mistakes. It’s good to go back over something, unpick it and see what we can learn. Nurses are central to this drive to draw things together and see how we can reduce risks in the future.’

At Luton and Dunstable Hospital NHS Trust, one of four hospitals chosen to take part in a safer patient initiative with the Institute of Health Improvement three years ago, safety is a two way street. Matron Vimla Sharma says ever since the initiative she has actively encouraged patient involvement in safety issues and reporting hazards to make sure that staff are alerted to problems as early as possible. Also, every ward has a patient safety champion and a patient safety board that displays, among other patient safety information, regularly updated details about the number of falls.

Ms Sharma says: ‘Patients have confidence in us because we are open. They like the fact that they can see how the number of incidents has fallen month on month.’

And for those trusts that are struggling to come to terms with these issues, she advises: ‘Just sit down and ask yourself: “What are the weaknesses in our service?” Be really honest with yourself. Start with small things and go from there. You can introduce new practices every day that will help to improve patient safety.’


Some questions to ask patients

  • Do you have to walk over or around cords or wires?

  • Do you have loose rugs or runners on the floor?

  • Were you to fall, do you have a system for calling assistance?

  • Do you have adequate lighting on your stairs and landing?

  • Is the floor in your bathroom vinyl or tiled flooring?

Tips to reduce risk of falls

  • Coil or tape cords and wires next to the wall

  • Remove rugs and runners or use double-sided adhesive carpet tape to keep them from slipping

  • A personal alarm pendant is a good way to obtain help quickly

  • 100 watt bulbs are recommended to give you adequate light

  • Non-slip mats, a fitted carpet or carpet tiles should be used in the bathroom

How to involve patients in improving safety will be a major theme of the NT Patient Safety Congress on 22–23 May 2008. For further details and to book, visit

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