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Patient Safety & Risk
Recently published guidance, policies, articles and reports
October - December 2016
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Choosing Wisely
The Academy of Medical Royal Colleges has published a list of 40 treatments that bring little or no benefit to patients. The list includes advice to both patients and doctors for treating health related issues. The list is part of the Choosing Wisely initiative which encourages doctors and patients to have fully informed conversation about the risks and benefits of treatments and procedures.
Investigations by the Parliamentary and Health Service Ombudsman
The Parliamentary and Health Service Ombudsman has published Report on selected summaries of investigations by the Parliamentary and Health Service Ombudsman October to December 2015. This report contains details of 100 cases it has resolved. They include complaints about avoidable deaths, GP out-of-hours care, delayed cancer diagnosis, poor hospital discharge and incorrect medicine dosage being given to patients. In all 100 cases, people complained to the organisation locally first. But there was a failure to resolve the complaints locally, meaning that they had to seek the help of the Ombudsman service.
Doctors low morale 'puts patients at risk’
The General Medical Council (GMC) has published The state of medical education and practice in the UK report: 2016. The report sets out an overview of issues that feature prominently in healthcare, after a prolonged period of upheaval in the sector, with growing service and financial pressures. Many doctors are feeling the pressure, a need to be supported at all levels, and this has an impact on professional standards and their own well-being. The level of dissatisfaction among doctors seems to be higher than ever before.
Education and training for sepsis
Health Education England has published Getting it right: the current state of sepsis education and training for healthcare staff across England. The purpose of this report is to provide a broad understanding of the current provision of sepsis education and training for healthcare staff across England. The report includes examples of good and innovative practice in sepsis training and highlights high quality educational resources which could be promoted nationally for use in sepsis training.
NHS England - New measures to support whistleblowers in primary care
NHS England is today confirming the steps it is taking to make it easier for primary care staff to raise their concerns so that action can be taken and improvements made. https://www.england.nhs.uk/2016/11/support-whistleblowers-pc/
RPS standards for reporting and learning for incidents
The Royal Pharmaceutical Society has published Professional standards for the reporting, learning, sharing, taking action and review of incidents. These standards describe good practice and good systems of care for reporting, learning sharing, taking action and review of incidents as part of a patient safety culture. Their implementation will improve patient safety and the quality of pharmaceutical services.
Morale of the medical workforce
The Royal College of Physicians has published Keeping medicine brilliant: improving working conditions in the acute setting. This report focuses on developing the evidence base to support new ways of assessing and improving doctors’ morale. The report also explores the issue of recruitment to the rank of medical registrar, and highlights that the perception of on-call roles as being extremely stressful and a significant deterrent to recruitment.
Female genital mutilation
The Home Office has publishes the Government Response to the Home Affairs Committee's report ‘Female genital mutilation: abuse unchecked’. The Government shares the Committee’s determination to eradicate the practice of female genital mutilation (FGM) and sets out its responses to the nine recommendations of the committee which are aimed ending FGM.
UK maternity care
MBRRACE-UK has published Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14. The report presents the findings of maternal mortality surveillance 2012 to 2014 in the UK and the lessons learned from the confidential enquiries into maternal deaths from cardiovascular causes, blood pressure disorders of pregnancy, early pregnancy causes together with messages for critical care.
Learning, candour and accountability
The Care Quality Commission has published Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England. This report presents the findings of a review into how NHS trusts identify, investigate and learn from the deaths of people under their care. It concludes that many carers and families do not experience the NHS as being open and transparent and that opportunities are missed to learn across the system from deaths that may have been prevented.
King’s Fund blog - What have we learnt about keeping people safer?
Following our recent event on keeping people safer in the health and care system, David Naylor, Senior Consultant in Leadership and Organisational Development, reflects on how the ‘implementation gap’ between theory and practice can be narrowed.
Confidential Enquiry into Maternal Death 2016
MBRRACE-UK is pleased to announce the publication on the 7th December 2016 of the findings of the third MBRRACE-UK confidential enquiry into maternal deaths - Saving Lives, Improving Mothers’ Care.
Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
HSE - Hospital fined after safety failings led to dementia patient’s death
http://press.hse.gov.uk/2016/hospital-fined-after-safety-failings-led-to-dementia-patients-death/?ebul=hsegen&cr=1/20-dec-16
Postpartum haemorrhage guideline
The Royal College of Obstetrics and Gynaecologists has updated their guideline Postpartum haemorrhage, prevention and mnagement (Green-top Guideline No. 52). This provides information about the prevention and management of postpartum haemorrhage), primarily for clinicians working in obstetric-led units in the UK.
Statistics - Never events data report - 1 April to 31 October 2016
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Articles
Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf. Aiken L.H. et al
Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach BMJ Open 2016.
Clinical Review
Patient Safety in the Emergency Department
The ED is inherently a high-risk setting for errors that can result in patient harm. This article outlines strategies for improving medication safety, transitions of care, health information technology, and other factors.
Emergency Medicine. 2016 September;48(9):396-404 Brenna M. Farmer, MD
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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: [21/12/2016]
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