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Patient Safety & Risk
Recently published guidance, policies, articles and reports
August - October 2016
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To access full text you may have to log in to your NHS Athens account (click here to register for free). If full text is not available then please email us to request a copy.
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September 2016
Research and analysis: Radiotherapy errors and near misses: biennial report
2 September, 2016
These reports (PHE-CRCE-029, PHE-CRCE-016, HPA-CRCE-035 and HPA-CRCE-002) summarise trends in radiotherapy errors (RTE).
Female genital mutilation
The House of Commons Home Affairs select committee has published Female genital mutilation: abuse unchecked. The Committee reported that it was "beyond belief" that thirty years after female genital mutilation (FGM) was made illegal in the UK there has been not one successful prosecution. The Committee were also concerned by reports that some clinicians are ignoring the duty on frontline healthcare professionals, social care workers and teachers to record data on FGM incidence, and repeat’s its call for the Government to introduce stronger sanctions for failing to meet the mandatory reporting responsibility.
Sepsis toolkit for GPs and healthcare professionals
The Royal College of General Practitioners (RCGP), in partnership with Health Education England and NHS England, has launched a Sepsis toolkit to support GPs and healthcare professionals to identify and manage the condition in patients. The toolkit also provides valuable information for patients, carers and parents, including an adult and child sepsis ‘symptom checker’, to illustrate the signs and symptoms they should look out for.
NICE Bites: Sepsis
The August 2016 NICE Bites bulletin from the North West Medicines Information Service covers Sepsis. The aim of this publication is to provide healthcare professionals with a clear and succinct summary of key prescribing points taken from the NICE guidance, NG51
Medicines and Healthcare products Regulatory Agency Press Release:
Dodgy kits give dodgy results
As part of FPA’s Sexual Health Week we are reminding people to be careful when ordering online and to always make sure medical devices used for sexual health has a CE mark and is bought from a legitimate online retailer. Some products being sold online may be counterfeit and will not give adequate protection against sexually transmitted diseases (STIs) including HIV.
Webinar: Involving patients in their own safety: Research findings and recommendations for action
Thursday 1 December 2016, 16.00 – 17.00
Drawing on new insights from research funded by the Health Foundation, the webinar will explore:
- the rationale for involving patients in their own safety
- how patients and clinicians conceptualise safety
- facilitators and barriers to patient involvement in safety
Register for this webinar
Safer pregnancy awareness campaign
The Department of Health, in partnership with Best Beginnings and Sands, have launched a campaign to raise awareness of safer pregnancies. Our Chance aims to give parents the knowledge and confidence to maximise their chances of healthy outcomes for themselves and their babies. It includes 25 short films, featuring real-life stories from parents and healthcare professionals.
IHI - Facing the Fear of Transparency
In the most recent post to his “Line of Sight” blog, IHI President and CEO, Derek Feeley, explores the key issue of transparency. “Transparency is a crucial characteristic for effective leadership in health care — especially leadership for improvement,” Feeley writes. Transparency also “opens up conversations with patients about their outcomes; their wants and needs; and their invaluable ideas about how to improve care.” He acknowledges that transparency isn’t easy for health care leaders — fears persist about sharing the good results of improvement work and the not-so-good ones. But Feeley asserts that being fully transparent with staff, patients, and the public at large is always the right thing to do.
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October 2016
Research and analysis: Safer radiotherapy: error data analysis
7 October, 2016
Analysis of radiotherapy errors and near misses reported voluntarily by NHS radiotherapy departments.
Open consultation: Providing a 'safe space' in healthcare safety investigations
17 October, 2016
Seeks views on creating a balanced 'safe space' to allow NHS staff to speak up about incidents without the fear of being punished.
News story: Improving the safety of maternity care in the NHS
17 October, 2016
New measures to make giving birth safer, including maternity safety funding and publishing maternity ratings, have been announced.
Safer maternity care: next steps towards the national maternity ambition. This Department of Health plan sets out measures that will be used to make NHS maternity services safer. The plans include publishing new maternity ratings for every clinical commissioning group to improve transparency, raising standards and giving families better information about the quality of local maternity services.
Maternity safety innovation fund: application form
Application form for NHS trusts and foundation trusts to apply for funding for innovative projects to improve their maternity services.
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Articles
How Well Is Quality Improvement Described in the Perioperative Care Literature? A Systematic Review.
Jt Comm J Qual Patient Saf. 2016 May;42(5):196-206.
Jones EL1, Lees N, Martin G, Dixon-Woods M.
1University of Leicester, University Hospitals of Leicester NHS Trust, Leicester, UK
Interprofessional learning on polypharmacy
Clinical Teacher. Volume 13, Issue 4, 1 August 2016, Pages 291-297
Anderson, E.a, Lakhani, N.b
a Department of Medical and Social Care Education, University of Leicester, United Kingdom
b Leicester School of Pharmacy, De Montfort University, Leicester, United Kingdom
The problem with root cause analysis.
BMJ Qual Saf. 2016 Jun 23. pii: bmjqs-2016-005511. doi: 10.1136/bmjqs-2016-005511. [Epub ahead of print]
Peerally MF1, Carr S2, Waring J3, Dixon-Woods M1.
1SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK.
2John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK.
3CHILL, Nottingham University Business School, University of Nottingham, Nottingham, UK.
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Resources used:
Applied Ergnomics
BMJ Quality & Safety
Daily Health Bulletin
Department of Health
Journal of the Royal Society of Medicine Open
Monitor
NHS Employers
NHS Health Education England
NHS Improvement
NHS Trust Development Authority
Public Health England
Links checked: [24/10/2016]
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