The latest patient safety related news
Follow this theme to discover what patient safety means as a practice. We share learning from practitioners, and researchers and findings from the developing field of human factors in health care.
Academy of medical Royal Colleges
An interim report by the Academy of Medical Royal Colleges’ Trainee Doctors’ Group (ATDG) that explores bullying and undermining within the medical workforce in the UK. It looks at current efforts to tackle problems and what further work is required.
Identifying and measuring patient safety hazards, incidents, errors, near misses, etc. is somewhat fraught. This systematic review examined record review as a means of detecting adverse events, particularly the reliability and validity of adverse event detection with record review.
Dr Foster has developed, in partnership with NHS Trusts, a new Early Warning Mortality metric based on more timely data as taken directly from trusts. This new approach allows: Access to timely data to allow faster identification of potential issues within 10 days of month end including mortality issues and faster assessment of the impact of any internal changes made to processes.
Healthcare Quality Improvement Partnership (HQIP)
Experts are urging neonatal units to form partnerships with neighbouring hospitals in a bid to reduce variation and drive up standards of care for very sick babies. The call comes as the latest National Neonatal Audit Programme report (NNAP), published today by the Royal College of Paediatrics and Child Health (RCPCH), found that very little or no improvement had been made over the last year in meeting several important care standards.
Parliamentary and Health Service Ombudsman
Commenting on the report by the Parliamentary and Public Administration and Constitutional Affairs Committee, which concludes that unsafe discharge from NHS hospitals is unacceptably high, as a result of political maladministration, Parliamentary and Health Service Ombudsman Julie Mellor said: ‘We see too many cases where discharge from hospital has gone horribly wrong, particularly for older, frail people who often don’t have the right support in place at home to cope on their own.
Health Education England & British Medical Association
The agreement provides junior doctors in England with legal protection if they are subjected to detrimental treatment by HEE as a result of whistleblowing (the HEE Agreement). The agreement also includes dentists in training.
This report provides the key findings from the Safeguarding Adults Collection (SAC) data collection for the period 1 April 2015 to 31 March 2016. This report presents information about adults at risk for whom safeguarding concerns or enquiries were opened during the reporting period, and case details for safeguarding enquiries which concluded during the reporting period. A safeguarding concern is where a council is notified about a risk of abuse, which instigates an investigation (enquiry) under the local safeguarding procedures.
Medication errors are one of the commonest forms of error and they can occur at almost any stage of the patient journey, including at home. Berrier’s commentary examines some of the issues around medication errors children can experience in the home. These include administration issues for parents, such as misunderstanding labels and dosing errors, as well as issues of health literacy.
Public Health Wales
The National Safety Standards for Invasive Procedures (NatSSIPs) have been created to bring together national and local learning from the analysis of Never Events, Serious Incidents and near misses, in an approach that will help NHS organisations to provide safer care to patients