Hospitals urged to review how far key emergency staff live from work

T his article aims to provide an Introduction to the work of the National Patient Safety Agency (NPSA), established as a special health authority within the NHS in July 2001. Patient safety, medical error and adverse incident reporting are high priorities in healthcare systems across the world. The NPSA will coordinate the efforts to report, and more importantly, learn from, adverse events occurring in the NHS. Part of the remit of the NPSA is to produce working solutions to prevent harm, specify national goals and establish mechanisms to track progress. This article will highlight some of the projects that will impact positively upon the work of infection control practitioners. The ‘Handy Hygiene’ project being undertaken by the NPSA will address the familiar concern of preventable healthcare-associated infection (HAI), which is estimated to cost the NHS nearly #1 billion a year.

Patients' safety

BackgroundIn the complex medical environment, clinicians commonly face varying challenges especially when undertaking invasive procedure with the risk of potential to harm patients. Checklists have a role in not only...

Recent reports indicate that approximately 10% of in-patients in UK hospitals are involved in an adverse event (these reports also state that 50% of these events are preventable). This is indeed a worrying finding, and indicates the need to look at how these incidents are handled or indeed, what is done to minimize their occurrence. The Department of Health, via the National Patient Safety Agency (NPSA) published a guide which is aimed at encouraging accurate reporting, learning from past events and changing the attitudes of key stakeholders (healthcare managers, frontline staf etc) towards risk taking and risk management. Our aim was to compare informally-learned and used risk assessment strategies volunteered by staff with the 'how to do it' guide published by the NPSA. We have compared each step of the NPSA guide with our empirical data relating to that activity. We interviewed forty-eight healthcare professionals (doctors from several specialties; nurses from a variety of settings; and an array of allied healthcare professionals). We used semi-structured interviews in order to discuss participants' views on their everyday working life, working relationships and patient safety. Our results indicate that healthcare professionals develop their own unique way to approach the issue of patient safety and risk, based on their professional raining, seniority and role within the hospital. They did share the conviction that frontline and support staff need to have immediate and easy access to information about past adverse events. They see this as a powerful tool in minimizing the reoccurrence of the same errors/problems, as well as a vehicle to improve staff morale by feeling valued and having their opinion heard. We believe that patient safety and welfare can benefit from the adoption of a more flexible and person-centred approach to how risk assessments are carried out. Enriching formal guidelines such as the 'Risk Assessment made easy' document with successful techniques and strategies which healthcare staff have informally developed has the potential to not only improve patient safety (since it will be based on the accumulated experience and knowledge of such staff) but also foster higher levels of self esteem amongst healthcare professionals.

The National Patient Safety Agency (NPSA) has been established to reduce the risk of patient safety incidents and promote learning across the National Health Service that will improve patient safety and help organisations to learn from the experience of others. One of the first projects has been to look at the way that infusion devices are purchased, stored and used within hospitals. This work has resulted in a number of recommendations centred on simplifying the range of devices available, using a centralised system to maximise use of the equipment and ensuring that staff are properly trained. The work has also involved manufacturers in the hope that future developments in equipment design will result in more user‐friendly devices that will reduce the risk of misuse and any consequent harm to patients. NPSA has just issued its first Safer Practice Notice to Trusts to highlight the issues around infusion devices and offer NHS organisations a toolkit to help them improve patient safety and make significant cost savings.

ObjectivesTo assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales.MethodsA multi-method study comprising (1) focus...

IntroductionEarly supported discharge (‘step-down’) and prevention of admission (‘step-up’) services require safe medicines reconciliation. Medication discrepancies at transfer of care are a potential cause of patient harm. There is currently...

BackgroundOpiates are frequently identified in medication incidents resulting in severe harm or death. The National Patient Safety Agency (NPSA) collects data pertaining to this and has made relevant recommendations.AimsTo identify...

The elimination or reduction of risk is a prime requirement of all healthcare workers. The matter has come to the fore in dermatological practice recently with the widespread use of effective drugs that have significant side-effects (e.g. retinoids, cytotoxic drugs, biologics), the increase in skin surgery, especially for skin cancer, and the extensive use of phototherapies. To examine the available database from different agencies to which adverse events may be reported over at least a 5-year time frame, categorize the risks, look forward to where as yet unidentified risks might exist, and draw conclusions to improve the safety of dermatological practice. This work came about through a request from the National Patient Safety Agency [to the Joint Specialty Committee of the British Association of Dermatologists (BAD) and Royal College of Physicians] for information on risks to patients receiving treatment or investigation for skin disease. Organizations in the U.K. that receive information about adverse events, whether caused by drugs or procedures in dermatological treatments, were approached for information about reported events over a 5-year (or, in one case, 10-year) time frame up to 2009. Data were received from the National Patient Safety Agency, the Medicines and Healthcare Products Regulatory Agency, the National Health Service Litigation Authority, the Medical Protection Society and the Medical Defence Union. In addition, the results of a survey conducted in 2010 by the BAD of its members concerning potential critical incident reporting were included. The received information was analysed according to category of event and conclusions drawn about how best to manage the risks that were identified. Adverse events were divided into the following categories, listed in order of the number of reports received: drug side-effects (biologics and retinoids), phototherapy dosage, drug monitoring (including initial screening), pregnancy prevention programmes, skin cancer follow-up (including acting on reports), dermatopathological reporting and conduct of dermatological surgery (including management of complications, equipment problems, use of lasers, cosmetic procedures and cryotherapy). Critical incidents reported by BAD members often concerned follow-up failures, e.g. of patients receiving systemic drugs or of those with skin cancer. Several of the reported adverse events concern systemic failures. Recommendations for risk reduction include the following points: better systems for drug monitoring (including regularity of attendance, provision of sufficient follow-up appointments, acting on results and adequacy of pregnancy prevention programmes); staff training and record keeping for phototherapy; acting on skin cancer multidisciplinary team meeting outcomes (including provision of sufficient follow-up appointments); and adequate training of staff in dermatological surgery including cryotherapy. Regular monitoring of the occurrence of such reports is needed to ensure safe practice and to identify early areas of new risk.

IntroductionIn 2007, the National Patient Safety Agency recommended that healthcare staff need to have full technical information about compatibility of commonly used mixtures used in specialist areas only (National Patient...

Gastrostomies are used as a medium to long term feeding strategy for children and adults with additional dietary needs or an inability to swallow, and they may be inserted surgically,...

Patients have the right to safe and quality health care (HC). They contact hospitals or other health care institutions (HCI) expecting help in restoringor strengthening health and do not expect to suffer any health damage or lose life. However, research shows that every tenth hospitalised patient suffers from adverse events (AE) resulting from shortcomings characteristic of a HC organisation orservice provision. More than half of AE could have been prevented provided systematic prevention measures had been implemented. The prevalence of AE and their damage to patients, HC organisations, the entire HC sector and national economies remains unacceptably high. Implementation of actions to improve patient safety (PS) and ensure the provision of safer patient care has become the most important HC challenge of the 21st century. Notwithstanding the extensive international PS movement that has emerged during the last two decades and plenty of international and national initiatives aimed at improving PS, a substantial breakthrough in ensuring safe patient care still remains a goal to be achieved. The main cause of disappointment is failure to implement international and national level PS improvement initiatives at the local (health care organization and its departments) level. There is no managerial adaptation mechanism to customize international and national level PS practices thus adapting them for hospital needs, specifics and potential. The article presents and substantiates the comprehensive management model of PS events (Model) for hospitals and other HC organisations to use as a basis in developing and implementing comprehensive systems for PS management with the aim of more effectively expanding the scope of safe practices and implementing prevention of PS events as well as improving their management. The proposed Model consists of three structural blocks the integrated interaction of which is aimed at ensuring: (a) identification of the best international and national PS practice and its implementation at hospitals; (b) creation of conditions necessary to develop safe practice with the aim of ensuring and improving PS at hospitals; (c) detection, evaluation and development of safe practice; (d) comprehensive prevention and management of unsafe practice at hospitals thus ensuring and improving PS and contributing to the improvement of performance and achievement of the goals of the entire organisation. The article discusses structure and functions of the Model, its integration witho ther activities within the organization, interaction with other institutions and organizations that participate in ensuring PS at hospitals, including problems related to its implementation at different hospitals.

This article analyses data received from a Freedom of Information Act 2000 request made to the National Patient Safety Agency in June 2010. Information was requested about adverse drug event reports in relation to insulin therapy and oral glucose-lowering agents in the care home setting. Data identified were reported to the National Patient Safety Agency between January 12005 and December 312009 and were processed through the National Reporting and Learning Service. There were 684 reports related to insulin and 84 incidents related to oral glucose-lowering agents. The most common error involved wrong or unclear dose: 173 reports for insulin, including one death, and 20 reports for oral glucose-lowering agents. Evidence shows that residents with diabetes in care homes are at risk of harm from adverse drug events involving insulin and oral glucose-lowering agents.

The National Patient Safety Agency (NPSA) was set up in July 2001 following the report An Organization with a Memory (Department of Health (DoH), 2000). This report recommended that the NHS would benefit from the aircraft business and the fact that lessons were learnt from every untoward incident. The report recommended that the DoH should examine the feasibility of setting specific targets for the NHS to achieve in reducing the levels of frequently reported incidents. For example it was suggested that by 2005 the number of instances of negligent harm in the field of obstetrics and gynaecology which result in litigation should be reduced by 25% (these cases currently account for around half the annual NHS litigation bill). Following the report An Organization with a Memory, the DoH's (2001a) published Building a Safer NHS for Patients which set out details of a scheme for national reporting of adverse incidents, together with recommendations for an improved system for handling investigations and inquiries across the NHS. Subsequently in July 2001 the NPSA was set up with the aim that there would be a mandatory reporting system for logging all failures, mistakes, errors and near misses across the health services (DoH, 2001b).

<h3>Aim</h3> To audit prescribing of intravenous fluids and monitoring of electrolytes against the National Patient Safety Agency (NPSA) guidelines and investigate the relationship between type of intravenous fluids and incidence of hyponatraemia. Administration of hypotonic intravenous fluids is a common practice in hospitalised children and can result in dangerous hyponatraemia (plasma sodium, P_Na &lt;130); commonest associations are sepsis, gastroenteritis and postsurgery. Children are known to be more susceptible to complications of hyponatraemic encephalopathy. NPSA recommends use of 0.9% NaCl if P_Na ≤135 mmol/l. <h3>Methodology</h3> Data were collected from all patients admitted with hyponatraemia between September 2007 and July 2009; their demography, underlying diagnosis, comorbidity, type of fluid prescribed initially and later and repeat blood results were analysed. The data were analysed using SPSS software (version 17.0) and manually using Excel spreadsheet. <h3>Results</h3> There were 78 case entries with hyponatraemia (P_Na &lt;135) during our study period. The mean age was 5.9 years (range 0.1–16.0). Bloods were repeated in 45% of total patients950% of Group 1 (P_Na ≤130), 46% of Group 2 (P_Na 131–133) and 42% of Group 3 (P_Na &gt;133). The numbers of times electrolytes were measured varied, with mean of 1.58, median 2.0 (range 0–4). Intravenous fluids were prescribed in 81% of Group 1, 51% of Group 2 and 70% of Group 3. 12.5% received 0.9% NaCl as maintenance fluids, of them 44% were Group 1. Among Group 1 36% received 0.9% Saline, 45% received 0.45% saline and 19% had oral fluids. While acute pneumonia and sepsis constituted 54% of Group 1 and 20% of total, gastroenteritis was 21% and postoperative patients 9% of the total. 45% of Group 1 and 29% of Group 3 had a comorbid condition. <h3>Conclusion</h3> The practice of intravenous fluid prescribing for maintenance and ongoing losses, coupled with monitoring of serum electrolytes during the study period did not meet the recommended standards of NPSA guidance published in March 2007. New guidelines have now been in effect since July 2009. We recommend a prospective audit with strict adherence to the guidelines to avoid possible disastrous consequences and ensure uniformity of practice.