Patient Safety Hero 2025 award announced
2 Jun 2025
Designed to evaluate the impact of a new therapeutic provision, this project focuses on improving positioning practices for neonates (a key component of developmental care, especially for premature and medically fragile infants) and uses PDSA cycles, PESTLE analysis, stakeholder mapping and the Hunter positioning audit tool. At the outset, monthly audits revealed that 100% of neonates required major repositioning however, by month 9, all neonates required only minor positioning adjustments – and this trend was sustained in subsequent audits. Key interventions included bedside demonstrations, staff training, parent engagement and collaborative dialogue with stakeholders. The judges were particularly impressed with how the iterative audit-feedback cycle helped identify improvements in real time, and fostered staff empowerment.
JOINT RUNNER-UP: Safety Planning Audit in Liaison Psychiatry 2023-2024 (Mosab Elbasuny & Thomas Manders); Liaison Psychiatry-Torbay Hospital, Devon Partnership Trust
A multi-site clinical audit focuses on patients presenting to Emergency Departments with suicidal ideation and self-harm — a high risk group. A robust five-cycle audit was conducted from June 2023 to December 2024, with clear outcome measures, tracking the inclusion of four core safety plan domains: coping strategies, support networks, means restriction, and service provision and follow-up. Interventions included a structured safety plan template, staff training, and MDT feedback loops, and results showed a substantial and sustained improvement in documentation quality and consistency.
JOINT RUNNER-UP: In-utero transfer (Dr Swasti Jain, Dr Subhasree Biswas, Mr Pradumna Jamjute, Claire Winthrop); West Cumberland Hospital, North Cumbria Integrated Care NHS Trust
This clinical audit evaluated the timeliness and quality of in-utero transfers for women ≤30 weeks pregnant with threatened preterm labour, critical to reducing neonatal mortality in this setting. It revealed suboptimal compliance with key elements of the national transfer care bundle, highlighting significant gaps in clinical practice and resulting in recommendations for improvement. These included ensuring availability of fFN kits, consistent documentation of QUIPP scores, inter-unit communication on steroid regimes, and re-categorisation of ambulance categories.