National Patient Safety Agency

Abstract International comparisons of previous convictions (PC) and crime scene behaviours (CSB) of stranger sexual offences can inform offender profiling strategies; especially the degree to which pragmatic models cross validate across countries. The present study compared PC and CSB of 474 UK and 418 Spanish cases. CSB and PC were analysed using Chi‐square. UK stranger sexual offenders displayed a higher proportion of all CSB analysed. UK offenders also had a significantly higher proportion of PC with the exception of violence offences. There were no significant differences in sexual pre‐convictions. In both the UK and Spain the CSB ‘reference to the police’ was significantly association with the PC ‘Criminal damage’ no other similar significant associations were found. Explanations for these findings include differences between the countries in regards to: legislation, crime recording processes, data coding processes, with additional consideration of any cultural, environmental and contextual factors.

BackgroundWith scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS) in England and Wales is an underused resource which collects intelligence from reports about health care error.MethodsUsing methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs) and 95% confidence intervals (CIs).ResultsThe largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%). Of those, 14,482/48,095 (30.1%) resulted in iatrogenic harm to the patient and 71/48,095 (0.15%) resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38); self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18); and infection control (OR 1.91, 95% CI 1.69, 2.17). We analyze these data to quantify the extent and type of iatrogenic harm in the specialty, and make suggestions on the way forward.Conclusion and level of evidenceDespite the limitations of such analyses, it is clear that there are many proven interventions which can improve patient safety and need to be implemented. Avoidable errors must be prevented, lest we be accused of contravening our fundamental duty of primum non nocere. This is a level III evidence-based study.

This article describes two initiatives from the National Patient Safety Agency, which were developed to address important areas of harm to patients. This harm stems from failing to recognise or respond appropriately to deteriorating patients and errors in pre-operative and peri-operative care of surgical patients. Both initiatives used principles of standardisation, reliability and human factors to develop tools and checklists to improve patient safety, with a common approach to supporting implementation. The article describes further advances and developments aimed at increasing and sustaining improvement, including the use of technology to reduce human error.

Evaluation is critical to continuous improvement. African Partnerships for Patient Safety (APPS) has 3 core objectives – partnership strength, patient safety improvement and patient safety spread – for which an evaluation framework was necessary. Action on health care-associated infections (HAI) provides a common platform of activity.

Patient safety in the perioperative setting is determined by many interdependent factors including reliable systems, good teamwork, psychological safety, optimal communications and most crucially shared vision and goals. The necessary organizational, environmental and behavioural conditions for quality care are not new and were in fact known to Florence Nightingale as much as 150 years ago. As noted by Nightingale, and something that remains unchanged today, the greatest threat to patient safety are the frailties of the human condition, complacent attitudes and unconscious behaviours. Recognizing that error is normal and somewhat inevitable, given the complexity of modern surgery, is undoubtedly the first step to mitigating error and harm, and the basis from which to tackle variability and sub-optimal conditions to deliver quality improvement.

Laparoscopic surgery is increasingly common—in 2005-6, 84% of the 49 077 cholecystectomies in England were undertaken laparoscopically.1 The technique is safe for most patients, and advantages include faster recovery and shorter hospital stay. A small number of people develop complications, however, some of which are specific to laparoscopy. These include gas emboli, arrhythmias, and shock when establishing the pneumoperitoneum (first step in any laparoscopic procedure). Injury to the bile duct and other organs is also more likely, given limited vision and control of the operative field compared with open surgery. Although most injuries are identified and dealt with during surgery, some are difficult to detect. One study of cases from US litigation claims showed that two thirds of laparoscopic injuries were initially missed.2 Some complications—such as diathermy damage to bowel, which results in late perforation or injury to the bile duct—may not present until several days after surgery.3 Late presentation of complications can cause problems because many laparoscopic procedures are done as day cases (sometimes in stand alone units). Signs can be subtle so may be missed by staff caring for patients after discharge in the community or on general wards. Delayed recognition of complications was the second most common reason for English litigation claims relating to laparoscopic cholecystectomy during the past 15 years.4 Between April 2005 and April 2010, healthcare staff in England and Wales reported to the National Patient Safety Agency (NSPA) 11 deaths and 37 serious incidents in patients who had deteriorated after laparoscopic surgery. These incidents are probably greatly under-reported, given what audit data show about complication rates.5 A typical incident reads: “The patient underwent laparoscopic cholecystectomy, deteriorated a day later. He was diagnosed with pancreatitis and …