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This is my one thing I can do to prevent one person from a bad outcome

My one thing is to get the message out to people who say colon cancer runs in my family....if so you need to follow through with your doctor or genetic clinic to be evaluated for hereditary colon cancer. http://www.nursingtimes.net/forums-blogs-ideas-debate/nursing-blogs/all-nurses-need-to-make-one-change-to-improve-patient-safety/5005181.article?referrer=RSS
All nurses need to make one change to improve patient safety
14 August, 2009 By Suzette Woodward
Suzette Woodward on how to implement just one change to aid patient safety
On 3 July the health select committee published the findings of its review into patient safety over the past nine months. While this could be seen as just another report on the subject it sharply reminds us of the things we still need to do to ensure the safety of patients in the NHS.
For those of us who work in this field it is an opportunity to raise the profile of patient safety and a reminder of the daunting journey we still have to make.
Someone reminded me the other day that patient safety is a bit like gardening, you have to keep at it, tending it and nurturing it to keep improving.
These recommendations help to build on the achievements so far. These are well documented in the report, which also works as a great synopsis of patient safety in the NHS over the past decade.
‘Someone reminded me the other day that patient safety is a bit like gardening: you have to keep at it, tending it and nurturing it to keep improving’
For example, the Department of Health established a national body, the National Patient Safety Agency, which in turn set up a national reporting and learning system. There have been a number of reports, including the DH’s Safety First in 2006 and the NPSA’s Seven Steps to Patient Safety in 2004. There have also been initiatives such as the Safer Patients Initiative by The Health Foundation, the Leading Improvement in Patient Safety training by the NHS Institute for Innovation and Improvement, the 1,000 Lives campaign in Wales, and Patient Safety First, the campaign for England.
Health select committee’s key recommendations on safety

Boards and senior management to make patient safety the top priority;
Commissioning, performance management and regulation arrangements must be clarified and rationalised to become more effective;
Patient harm rates must be measured by regular reviews of samples of case notes;
The introduction without delay of the NHS redress scheme;
Quick implementation of proven technologies that can improve safety;
Ensuring harmed patients and their families always receive full and frank information about incidents of harm;
Enabling healthcare workers on the frontline to use their initiatives to help improve patient safety in the NHS;
Better and more explicit patient safety education for healthcare workers.
However, sometimes reports and their recommendations can feel very distant from frontline delivery. To try to make the recommendations of the health select committee’s report feel more relevant to your day-to-day work and a less daunting task to implement, there are a number of things you can do. Start by thinking of a few things you would like to change in your area or your practice to make it safer.
Talk to your colleagues and find out what they would like to change. Choose one thing you all agree on and create a sense of community with this shared purpose. Set yourselves clear and achievable goals so that everyone knows what they are expected to do.
Your goal needs to connect to a real outcome and be embraced by everyone. Bring people together around these shared values, common interests and shared goals. Then try changing this ‘one thing’ and measure the difference it makes.Don’t worry about statistical analysis, create a simple graph and plot the measures over time.
If you want help with this, The How-to Guide for Measurement for Improvement can be found at www.patientsafetyfirst.nhs.uk. It includes information on how to make measures meaningful, the different types of measures you can use and advice on analysing your data.
Your one change should add to the bigger picture of trying to improve the quality and safety of patient care in your organisation. If it doesn’t achieve that aim, ask yourself why not.
When you give this process a go, share your story with others in your hospital or community. If you like, you can choose to celebrate this or carry out your actions in Patient Safety First Week during 21-27 September.
This is a week when everyone can do one thing for patient safety - a bit like Comic Relief’s Red Nose Day, although no one is required to sit in a bathtub full of baked beans. While we need a sense of urgency we absolutely need a sense of hope, too. So if we all do one thing during this week we will start to make a bigger difference together.
To access the health select committee’s Patient Safety report go to http://tiny.cc/healthselectcom
Suzette Woodward is nursing lead for patient safety at the National Patient Safety Agency
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