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This toolkit provides information about how the US Department of Health and Human Services Office of the Director General conducted recent medical record reviews to identify patient harm. It outlines the decision criteria for adverse events and describes the methods used in the report, 'Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm' in October 2018, building upon a broader series of reports about adverse events in hospitals and other health care settings.

Despite the prevalence of diabetes amongst individuals with Serious Mental Illness (SMI), diabetes care is not currently audited within mental health inpatient settings as it audited in physical health settings. This project piloted an audit to assess the diabetes care within London NHS Mental Health Trusts. The Health Innovation Network in partnership with South London and Maudsley NHS Foundation Trust (SLaM) developed and piloted a diabetes audit. Following the SLaM pilot, the audit was completed by all nine London Mental Health Trusts. A diverse approach was taken to spread and adoption. This included piloting the audit within one MH Trust, refining, and then rolling out the audit to eight London Mental Health Trusts.

This report by the National Audit of Dementia (NAD) presents the results of the fifth round of audit data. For the first time, the audit has been undertaken prospectively, which will enable hospitals to take earlier action to improve patient care and experience. However, this has demonstrated that many hospitals still have no ready mechanism to identify people with dementia once admitted. One notable improvement is delirium screening (dementia is the biggest risk factor for developing delirium). Screening for delirium has improved from 58% in round 4 to 87% in the current audit. In addition, a high number of pain assessments are also being undertaken within 24 hours of admission (85%). Although encouraging, the report highlights that 61% of these assessments were based only on a question about pain—an approach that can be unreliable in patients with dementia. While this report acknowledges that our health services have experienced an extraordinarily difficult and challenging time, it does shine a light on a need for more training. It states that is encouraging that many staff have received Tier 1 dementia training (median 86%), but suggests that a much higher proportion of ward-based patient facing staff should have received Tier 2 dementia training (median 45%). It found that only 58% of hospitals are able to report the proportion of staff who have received training. As such, the report recommends that any member of staff involved in the direct care of people with dementia should have Tier 2 training, and this training should be recorded to provide assurance to the public and regulators.

The aim of the NHS Safety Thermometer is to provide a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free care’. Data is collected by Trusts on pressure ulcers, falls, urinary tract infections (UTI), and Venous Thromboembolism (VTE) assessments, prophylaxis and treatment. The North East Quality Observatory Service (NEQOS) Safety Thermometer Tool allows trusts to compare themselves against their peers (for improvement purposes) as well as to undertake internal comparisons across different service areas within the Trust. Produced quarterly, the tool uses National Safety Thermometer data published by NHS Digital and presents this by Trust across the North East & North Cumbria (NENC) area, providing comparisons between peers as well as with the national average, with breakdowns by service areas for detailed analysis.

NHS services have been under increasing pressure in recent years, particularly since the start of the Covid-19 pandemic. We have previously reported on the NHS’s efforts to tackle the backlogs in elective care and its progress with improving mental health services in England. This report gives an overview of NHS services that may be used when people need rapid access to urgent, emergency or other non-routine health services, and whether such services are meeting the performance standards the NHS has told patients they have a right to expect. It covers: general practice community pharmacy 111 calls ambulance services (including 999 calls) urgent treatment centres accident and emergency (A&E) departments.

This study in the Journal of Patient Safety outlines the development of the Leapfrog composite patient safety score. The researchers aimed to develop a composite patient safety score that provides patients, healthcare providers and healthcare purchasers with a standardised method to evaluate patient safety in general acute care hospitals in the United States. The study concluded that the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety.

This stocktake by NHS Confederation highlights insights from medicines optimisation forums on the experience of ICS medicines optimisation so far: the opportunities that exist, the barriers experienced, the support that is needed, and what the vision for medicines optimisation could achieve.

Significant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.

This article in USA Today looks at how the Covid-19 pandemic has caused setbacks in hospitals' patient safety progress. It looks at data from a report by the US non-profit health care watchdog organisation, Leapfrog, which show increases in hospital-acquired infections, including urinary tract and drug-resistant staph infections, as well as infections in central lines. These infections spiked during the pandemic and remain at a five-year high. The article also looks at the case study of St Bernard Hospital in Chicago, which was rated poorly by Leapfrog on handwashing, medication safety, falls prevention and infection prevention, but then made huge progress in improving safety. It describes the different approaches and interventions taken by St Bernard.

The National Audit of Care at the End of Life (NACEL) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). It was carried out by the NHS Benchmarking Network in collaboration with The Patients Association and aims to assess the quality of care that patients receiving end of life care and their families experience, as well as staff perceptions of their confidence and ability to deliver end of life care. The audit included: an Organisational Level Audit covering Trust/Health Board and hospital/submission level questions for 2020/21. a Case Note Review which reviewed 20 consecutive deaths between 12th April 2021 and 25th April 2021 and 20 consecutive deaths between 1st May 2021 and 14th May 2021 for acute providers and up to 40 consecutive deaths in April and May 2021 for community providers. a Quality Survey completed online, or by telephone, by the bereaved person. a Staff Reported Measure, completed online. Key findings Recognising the possibility of imminent death The possibility that the patient may die within the next few hours/days was recognised in 87% of cases audited, compared to 88% in 2019. The median time from recognition of dying to death was recorded as 44 hours (41 hours in 2019). Communication with the dying person Results on all key metrics regarding the recording of conversations with the dying person remain similar to 2019, pre-pandemic levels However, from the Quality Survey, the proportion strongly disagreeing or disagreeing with the statement ‘staff communicated sensitively with the dying person’ increased from 7% (2019) to 11% (2021). Communication with families and others There was little change in 2021 when compared to 2019, with continued high compliance on recording of conversations about the possibility that the person might die and on the individualised plan of care. As in 2019, discussions on hydration and nutrition with families and others were documented, or a reason why not recorded, in only around half of cases. Involvement in decision making Findings from the Case Note Review in 2021 suggest continued strong compliance on involvement in decision making, with similar results to those reported when this theme was last tested in 2018. However, from the Quality Survey, in 2021, 23% of people felt they would like to be more involved in the person’s care compared to 19% in 2019. Individualised plan of care Third round findings from the Case Note Review showed similar results for the existence of an individualised plan of care, 73% of cases compared to 71% in 2019, suggesting this is an ongoing area for improvement. Documented evidence of an assessment of wider needs such as emotional/psychological, spiritual/religious/cultural and social/practical shows a reduction since 2019, which may be a result of continuing pressures of the Covid-19 pandemic on services during 2021. Needs of families and others The needs of the family were identified as an improvement area in both round one and round two of the audit. Comparison with 2019 findings suggests performance has deteriorated, which may reflect the impact of the pandemic on the ability of visitors to access wards and the capacity of staff to assess and address the needs of families and others. Families’ and others’ experience of care The overall rating of care and support to the person who died, and the overall rating of care and support provided to families and others, are lower than in 2019. Governance Governance was last measured in 2018 and Trusts/Health Boards (HB) continue to show high compliance with the existence of key policies related to care at the end of life in 2021. Workforce/specialist palliative care The results show an improvement in access to specialist palliative care, in particular, face-to-face access 8 hours a day, 7 days a week was available in 60% of hospitals/sites compared to 36% in 2019. The increased provision may reflect a response to the pandemic and it is not yet clear whether the change will be permanent. Staff confidence Staff completing the survey expressed confidence in recognition of dying, communication, responding to the needs of the dying person and those important to them, involving people in decision making, accessing specialist palliative care and managing pain and physical symptoms, with less than 6% stating they strongly disagreed or disagreed with positive statements of confidence in these areas. Staff support Training was identified as a potential area for improvement with only 49% of respondents stating they had completed training specific to end of life care within the last three years. Although staff felt support was available from the specialist palliative care team, only 66% felt managerial support was available to help provide care at the end of life. Care and culture Although 83% felt able to raise a concern about end of life care, this should be closer to 100%. Only 80% answered positively that they felt they work in a culture the prioritises care, compassion, respect and dignity, which is also a concern.

The Sentinel Stroke National Audit Programme (SSNAP), which assesses the care provided for patients during and after they receive inpatient care following a stroke, has published its ninth annual report. Based on data from April 2021 to March 2022, the report aims to identify which aspects of stroke care need to be improved with a particular focus on changes in stroke care over the last two years and the ‘roads’ that need to be followed in order to restore the quality of care. SSNAP measures the process of care against evidence-based quality standards referring to the interventions that any patient may be expected to receive. These standards are laid out in the latest clinical guidelines and include: whether patients receive clot busting drugs (thrombolysis). interventions for clot retrieval (thrombectomy). how quickly they receive a brain scan. how much therapy is delivered in hospital and at home.

The National Audit of Inpatient Falls (NAIF) has published its latest report into the care given to patients who fell while they were in hospital and sustained a hip fracture. Based on data from 1,394 patients in 2021, the report presents information on post-fall management and tracks performance against National Institute for Health and Care Excellence (NICE) Quality Standard 86, which includes checking the patient for injury before moving, using safe lifting equipment and prompt medical assessment after the fall.

Established in 2006, the National Neonatal Audit Programme (NNAP) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and delivered by the Royal College of Paediatrics and Child Health (RCPCH). It assesses whether babies admitted to neonatal units receive consistent high-quality care in relation to the NNAP audit measures that are aligned to a set of professionally agreed guidelines and standards. The NNAP also identifies variation in the provision of neonatal care at local unit, regional network and national levels and supports stakeholders to use audit data to stimulate improvement in care delivery and outcomes. This report summarises the key messages and national recommendations developed by the NNAP Project Board and Methodology and Dataset Group, based on NNAP data relating to babies discharged from neonatal care in England and Wales between January and December 2021.

The British Thoracic Society has published the results of their 2019 national audit of acute non-Invasive ventilation (NIV) in adult patients in NHS hospitals.   Data were collected in 2019, before the pandemic, and the audit did not look at things such as pandemic preparedness or numbers of NIV hardware available, but at the quality of the service provided. The audit analysed data provided from over 150 hospitals, for a total of over 3500 patient records, and looked for adherence to our quality standards in the provision of the service.

National audits, such as the National Emergency Laparotomy Audit (NELA), are a powerful tool. They allow us to see what is happening to our ‘real-life’ patients, to identify gaps in our local services, to see which hospitals are doing best and to share best practice. This learning informs guidelines and pathways such as ‘The High-Risk Surgical Patient’ and the forthcoming international enhanced recovery programmes for emergency laparotomy. The linking of good practice with a financial incentive, the Best Practice Tariff, has also acted as a carrot for hospitals to support funding for new models of care. Previously we have seen how audit, linked with guidelines and associated financial incentives, has improved outcomes in hip fracture and now it is encouraging to observe similar results in emergency laparotomy. In this blog, Dr Jugdeep Dhesi, Consultant Geriatrician and Deputy Director for the Centre of Perioperative Care, discusses NELA and older patients, and how we must deliver patient-centred rather than surgical-speciality based pathways and to ensure the best outcomes for all of our patients.

Barnsley NHS Trust Head of Nursing Quality Gavin Portier and Patient Safety Learning Founder and Chair Jonathan Hazan sit down to discuss how positive messaging and learning around patient safety produces positive outcomes.

This easy-read guidance outlines what the Care Quality Commission (CQC) expects good care to look like for autistic people and people with a learning disability. It explains how the CQC aims to help health and adult social care services develop and run services that are right for the people they serve.

This national data collection project has been commissioned by NHS England (NHSE) and is run by the NHS Benchmarking Network (NHSBN). The aim of the project is to understand the extent to which organisations are complying with the NHSE Learning Disability Improvement Standards, and to identify improvement opportunities. Compliance with these standards requires organisations to assure themselves that they have the necessary structures, processes, workforce and skills to deliver the outcomes that people with learning disabilities and their families and carers, expect and deserve. This project aims to collect data from a number of perspectives to understand the overall quality of care across Learning Disability services. Read summary reports from previous years of the NHS England Learning Disability Improvement Standards project.

The Cappuccini Test is a simple six-question audit designed to pick up issues relating to supervision of anaesthetists in training and non-autonomous SAS grades (NASG) who do not fit the description in Guidelines for the Provision of Anaesthesia Services (GPAS) of 'SAS anaesthetists that local governance arrangements have agreed in advance are able to work in those circumstances without consultant supervision.' The test is named after Frances Cappuccini, who died giving birth to her son at Tunbridge Wells Hospital in 2012. The coroner’s inquest into her death noted that supervision arrangements for anaesthetists at the trust were ‘undefined and inadequate’. The test was developed for hospitals to assess the level of supervision given to their SAS and trainee anaesthetists, and to make improvements with the aim of improving the safety of patients.