Clive Flashman

and an update on this article published in the  Health Service Journal today

Hi @Kenny Fraser, thanks for taking the time to respond.

Yes, not having an EPR is definitely risky as it precludes the sharing of information, certainly within a single organisation. In terms of an assessment, I would guess that something like that was done at the beginning of the National Programme for IT back in 2003, but I've not seen anything more recently. With regard to benefits realisation, this is a useful document to look at: https://www.ouh.nhs.uk/patient-guide/documents/epr-case-study.pdf 

In terms of the safety reviews that EPRs have to go through, as you can imagine, they are a lot more robust than DTAC. There is an extremely detailed safety hazard assessment that was created by Dr Maureen Baker and others as part of the NPfIT roll out in the mid 2000s. That is where much of the slimmed down DCBs and DTAC material has come from. However, there are limitations to the self-assessed reviews, and there will always be 'snags' picked up post implementation. 

My key worry is that this 'post-market surveillance' is not sufficiently specified, or generally done, and while DCB0129 and DCB0160 are meant to be repeated also as part of this process, that hardly every happens.

That's great news @Chris W, would be good to share the results of that with the wider group @Patient_Safety_Learning

I am glad that the remit of PSPs has gone far beyond that originally envisaged by NHS E. This can only be a good thing.

It would be interesting to collate this into a master job spec that can be shared across Trusts so that all can fully benefit from the input of their PSPs.

Perhaps this can be done via the relevant area on this site @Claire Cox, @HelenH, @PatientSafetyLearning Team

If it is correct that the babies' deaths were reported into the local risk management system as medication errors, they would also have been reported onwards to the National Reporting and Learning System (NRLS); run by NHS England and all data analysed by them also.

Given that these death records in the NRLS  would have shown that they all occurred at the same Trust, involving babies, in the space of a 12-18 month period, I wonder whether this should have been picked up centrally?

Thanks Richard, it is certainly not easy as a patient to get your voice heard, but we carry on looking to improve this through the conversations we have....

Hi @Derek Malyon
sorry that you didn't get more traction from the AHSN, it's a tricky time at the moment but there is no excuse for being unresponsive like that. If I can think of another 'way in' I'll let you know.
Kind regards, Clive

FOR SW AHSN, contact xxx@xxxx
(07496 xxxxxx)

My pleasure @Derek Malyon

In the new year, I suggest you link up with your local AHSN, and have a conversation with them before sending your PDF with a covering email. I think the 'ask' needs to be as clear as possible. You would like them to trial the eQMS on x wards with y patients for z months, and then explain how the impact will be independently evaluated at the end of that.

Hi @Derek Malyon
I think you need to give them a bit more info, for example:
1. Eliminate the acronyms
2. What is the purpose of the solution (in more detail)
3. Is it only for use in hospital on wards, or elsewhere?
4. Has it already been trialled in the NHS or elsewhere? If so, what were the results?
5. Have there been any academic evaluations of impact?
6. Why is it different/ better to what is already being used in the NHS?
7. How cost-effective is it?
8. the ASK - what do you want from them? What do you want them to do?

@Derek Malyon and @HelenH
the typical route for innovation to enter the NHS is via the 15 regional Academic & Health Science Networks. Depending on where you are based Derek, you should make enquiries of your local AHSN to see if they can help you to promote your ideas into the NHS. If you have already tried that route then I'd be interested to hear what happened.

A PS Manager from a Trust told me recently that the investigations they did there were largely driven by the contract with their CCG. They HAD to investigate every serious pressure ulcer. The recommendations were generally the same, and nothing ever changed. Perhaps @Jon Holt the CCGs might change so that there is less emphasis on repeating investigations into an issue ad infinitum, and more emphasis on actual implementation of recommendations and evaluating the impact of them.

@Dominic Claxton

This is something that the RCGP ought to be giving some guidance on really

Great summary! Thanks @Richard Price

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,

A really great article and so important that we are reminded to use language that everyone can understand, it's so easy to lapse into those TLAs (three letter acronyms!!!)

This is really useful! Thanks so much for sharing it

can you post the link please @HelenH ?

wow! I remember this being an issue that we discovered in the data being reported to the NRLS soon after we launched it in 2003. I had thought that we had issued a patient safety alert on it soon afterwards. It is sad to see that 15 years later, these incidents are still happening

Hi Luke, this sounds like a great initiative - well done.
Thought it was worth alerting you to the app libraries produced by ORCHA (who also power the national NHS Apps Library).
Have a look at their unfiltered Apps library to get a feel for what I am talking about (if you don't already know about this):
www.appfinder.orcha.co.uk 

Kind regards, Clive