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  • An organisation losing its memory? Patient safety alerts: implementation, monitoring and regulation in England (AvMA, 28 January 2020)

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • AvMA/David Cousins
    • 28/01/20
    • Health and care staff, Patient safety leads, Researchers/academics

    Summary

    This report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients.

    The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.

     The report recommends a number of urgent actions to address these risks to patients.

    An organisation losing its memory? Patient safety alerts: implementation, monitoring and regulation in England (AvMA, 28 January 2020) https://www.avma.org.uk/wp-content/uploads/Patient-safety-alerts-FINAL.pdf
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    This report raises some really important questions about who has responsibility for monitoring this, noting that the ‘role and responsibility of national organisations to oversee the implementation of these alerts was unclear and ineffective in some cases’.

    Who should be responsible for this? NHS England and NHS Improvement, the CQC or perhaps the National Patient Safety Alerting Committee? You can find the full Patient Safety Learning response here: https://www.patientsafetylearning.org/blog/response-to-avma-report-patient-safety-alerts

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    Thank you for sharing your response to the AvMA report.

    In your organisations’ Blueprint for Action’, you highlight data and insight for patient safety as one of the six foundations of safe care. You recommend  health and social care system to develop models for measuring, reporting and assessing patient safety performance to identify and address shortfalls in performance. These recommendation is very similar to those included in the AvMA report.

    You ask the question whether the National Patient Safety Alerting Committee (NaPSAC) might be best placed to perform this role. This body’s core purpose is to ‘agree progress and oversee systems that will clearly identify which nationally-issued patient safety advice and guidance is safety-critical’

    This could be a role for the committee, but only after it’s remit and that of the Patient Safety Team at NHS Improvement have been clarified to once again include known/wicked risks previously identified in patient safety alerts, and more detailed information about all major risks identified from reports to the NRLS is again shared openly.

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    Hi David, a very good point. And a general one about the role of NHSI with regard to patient safety and incident reporting. NHSI is leading on replacing the now outdated NRLS. How will this inform learning and action? Will all risks reported be analyses and transparently reported. Will this be accompanied by the insight from Trusts that have responded with improvement action and advice for others #share4safety

    What do people think?

    @Clive Flashman

     

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    I think that realistically, patient safety alerts can only be actively monitored for a finite period of time, say 2 years post-publication. However, one of the things that we had already identified as a future enhancement to the NRLS 16 years ago, was the desire to track incidents that resulted due to issues related to an existing patient safety alert. There was a never a clear and straightforward way to accurately track these and determine the impact (positive or negative) of a patient safety alert. Data quality (as ever) in the NHS is also an issue.
    In these days of AI and ML, it seems logical that these types of incidents should be more easily identifiable, trackable and remedial actions then taken if necessary,

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