Jump to content

Search the hub

Showing results for tags 'Audit'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous


  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Learning news archive
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous


  • News


  • Files


  • Community Calendar

Find results in...

Find results that contain...

Date Created

  • Start

Last updated

  • Start

Filter by number of...


  • Start



First name

Last name


Join a private group (if appropriate)

About me



Found 35 results
  1. Content Article
    Key findings The increase in incidence of Type 1 diabetes observed in the first year of the Covid-19 pandemic was followed by a continuing increase in the numbers newly diagnosed with the condition in 2021/22. Almost all of those with Type 2 diabetes were overweight or obese, and almost half had a diastolic or systolic blood pressure in the hypertensive range Despite reductions in the percentages recorded as requiring additional support between 2020/21 and 2021/22, over a third of children and young people were assessed as requiring additional psychological support outside of multidisciplinary meetings Inequalities persist in terms of the use of diabetes related technologies in relation to ethnicity and deprivation. Recommendations Commissioners should ensure adequate staffing of full multidisciplinary diabetes teams to manage the increasing numbers of cases of Type 1 and Type 2 diabetes observed since 2020, who are trained to facilitate the optimal use of new diabetes-related technologies. Children and young people with Type 1 diabetes should have equitable access to diabetes care, irrespective of social deprivation, ethnicity or geography. They should be offered a choice of diabetes technology that is appropriate for their individual needs with families being made aware of the potential differences in outcome with different modalities of insulin delivery and blood glucose monitoring. Health checks for children and young people with diabetes are essential for early recognition of complications. The need for tests and the results should be clearly communicated to families as part of their individual care package, and completion rates of checks should be monitored through the year. Awareness of diabetes symptomatology amongst the public should be enhanced to avoid newly diagnosed children and young people presenting with Diabetic ketoacidosis (DKA). Studies should be funded to derive evidence for interventions supporting pre-diabetic children young people to avoid progression to Type 2 diabetes.
  2. Content Article
    The definition of ‘success’ for incontinence mesh surgery was based on The British Society of Urogynaecology (BSUG) ‘pad test question’, which looked at whether a woman was using fewer incontinence pads after surgery. Like most women who had a mesh sling for incontinence implanted, I passed this test with flying colours. But the complications I experienced as a result of the surgery were painful, debilitating and life-changing, an experience shared by thousands of women who have had a pelvic mesh implant. For both incontinence and prolapse mesh, outcome logging merely looked at whether the prolapse had been fixed and did not query the onset of new pain or complications. Lack of follow-up, data collection and recognition of mesh as the cause of women's symptoms when they present with complications has led to a gross underestimation of the scale of pelvic mesh-related harm. So the prospect of an audit that would look to remedy this was a positive one. In 2020, the final report of the Independent Medicines and Medical Devices Safety (IMMDS) Review, ‘First Do No Harm’, called for “a retrospective audit and follow-up of women who had pelvic mesh surgery in 2010,” to be conducted by NHS Digital. The report highlighted that this should provide “far greater detail on mesh complications in the decade after surgery,” and that NHS Digital should make “every effort” to obtain sufficient data.[1] On 5 December 2022, the Minister for Women, Maria Caulfield MP, confirmed in the Commons that an audit had been completed following the acceptance of the IMMDS Review’s recommendation and would be published in 2023.[2] However, the record later had to be corrected, as it became clear in a further parliamentary question that, contrary to the stated intention of NHS Digital who conducted the audit, “...only Hospital Episode Statistic data was used in the audit and no other data was employed. Patients were not contacted as part of this audit.”[3] History repeats itself - the NHS audits the same data I was horrified to find out that instead of making “every effort” to get accurate information, NHS Digital have simply repeated the same exercise they carried out in 2018 in their retrospective audit of annual Hospital Episode Statistics (HES) data on mesh implant procedures. For the 2023 audit, they used the same approach taken in the 2018 audit and exclusively used HES data. This approach was highlighted in ‘First Do No Harm’ as being “widely criticised for its omissions, [for example] lack of any private sector data and for its implied underestimate of long-term complications.”[1] I wrote to the Health and Social Care Select Committee on behalf of Sling the Mesh in December 2022 to highlight the shortcomings of using HES data in isolation.[4] The Committee shared our concerns, highlighting that: “Without records of which patient has undergone which procedure, or been prescribed which drug, the health system will continue to, in the words of the IMMDS review team, “fly blind”... Although the retrospective audit of mesh implants is an encouraging first step, it will be unlikely to reflect and take into account all of the adverse effects women have experienced due to the nature of data used in the audit. We therefore recommend that the Government consider an alternative strategy for how to proactively contact those who have had the procedure about their postoperative experiences and possible side effects.”[2] NHS Digital’s approach does not paint a true picture of the extent of the harm caused by pelvic mesh. There are many issues with using purely HES data for a mesh audit, namely that: HES data does not capture complications, as women have not been followed up and therefore the spectrum of suffering has not been logged. it does not take into account any data from GPs or primary care, where potentially thousands of women have sought help for their mesh complications. Most of these women will not yet have set foot in a hospital for consultation or treatment. it does not take into account data from private hospitals, which may be recorded differently or not have been logged at all. there are discrepancies in how pelvic mesh insertion and removal is logged by different trusts and healthcare professionals. HES data sometimes lacks necessary detail on the nature of treatment. For example, until recently, there was no specific HES code for rectopexy mesh insertion or removal, which means the specific issues associated with this surgery are difficult to identify through data. How should the Government conduct an audit of mesh patients? If the Government is serious about understanding the true extent of harm caused by pelvic mesh, it needs to contact all women who have had mesh surgery within a specific time period to establish whether they have had complications or injuries over the following years. Mesh has a ticking time bomb nature, in that it can be fine for many months or even years before causing problems like erosion, so this long term follow-up is crucial to gauge the extent of harm. Instead of using unreliable and incomplete data, an audit needs to take the approach of the Paterson Inquiry and recall all affected patients.[5] If the cost of such an exercise would be prohibitively high, they could take a sample of women from across the country and use their findings to estimate the extent and nature of harm caused by pelvic mesh. Why is a reliable pelvic mesh audit important? Being able to quantify the extent of the harm is important so that we can establish an accurate figure of risk; what percentage of women suffer harm due to pelvic mesh, and what is the likelihood of more of them developing complications in years to come? Until we have this knowledge, the Government and regulatory system can’t learn the necessary lessons from the mesh scandal to ensure other devices don’t cause this degree of harm. Health services will also continue failing women when they seek help for injuries and complications that are likely to have been caused by mesh. So many women have also been subject to the secondary harm of gaslighting and not having their symptoms taken seriously by healthcare professionals. Having accurate data on harm caused by mesh would help put an end to the healthcare system seeing women’s concerns as ‘hysterical hearsay’. It would also help women understand that their complications must be taken seriously and that their symptoms are not ‘all in their heads’. Why is the Government not pushing for an accurate audit? When compared to the Government response to Paterson, the retrospective mesh audit seems like a token effort. Why is the Government less willing to understand and tackle the issues associated with mesh complications? Perhaps because, rather than being the responsibility of “one bad apple”, the harm caused by pelvic mesh is the responsibility of a system that failed to research, regulate and monitor the effects of medical devices designed to be implanted inside people’s bodies. There is also the fact that knowing the true extent of the harm caused by pelvic mesh has the potential to create a huge financial burden, if the Government ever agrees to fulfil its responsibility to set up a Redress Agency for women harmed by pelvic mesh surgery. Related reading The difficulty of medical negligence cases and why financial redress from the Government is so important for mesh victims (17 January 2023) Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh - a Patient Safety Learning blog (19 July 2022) “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery (1 May 2022) References 1 First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020 2 Health and Social Care Select Committee: Follow-up on the IMMDS report and the Government’s response Sixth report of session, 20 January 2023 3 Question on surgical mesh implants. Parallel Parliament, 14 December 2022 4 Letter to Health Select Committee December 2022. Sling the Mesh, December 2022 5 Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson. Department of Health and Social Care, 16 December 2021
  3. Content Article
    Key findingsPatients experienced long delays from time of arrival at hospital to time of surgery, including those with sepsis suspected at arrival in hospital (median 15.6 hours to theatre)Many patients (77.7%) with suspected sepsis on arrival did not receive antibiotics within an hour of arrival in hospitalOne in five high-risk patients did not receive postoperative care in a critical care unit.Frailty doubled the risk of mortality of patients aged 65 and over (13.0% vs 5.9%), but review by a member of the elderly care team was associated with a significant reduction in mortality (5.9% vs 9.5% amongst non-frail patients, and 13.0% vs 22.3% amongst frail patients). However, this is not routine practice in many hospitals.
  4. Content Article
    The report contains a number of findings related to: patterns of care at diagnosis staging and treatment planning waiting times along the care pathway curative surgery non-curative treatments. It also includes findings relating to the impact of the Covid-19 pandemic, including: In April 2020, the number of patients diagnosed with OG cancer was 43.6% of the 2019/20 monthly average, falling from 837 to 365 cases per month. The numbers diagnosed soon returned to normal levels, and in the period from June 2020 to March 2021, the number of monthly cases was 97.8% of 2019/20 levels. The percentage of patients diagnosed with stage 4 disease (advanced cancer) increased from 41.6% in 2019/20 to 44.9% in 2020/21. The report also contains recommendations for healthcare professionals, among which is including a call to review patients diagnosed after emergency admission and undertake root cause analysis to identify opportunities to reduce rates of emergency diagnosis.
  5. News Article
    German public research funder Deutsche Forschungsgemeinschaft (DFG) is conducting an audit of the clinical trials it has supported in the past. The audit was announced in response to a request from TranspariMED asking DFG for a list of all its trials completed between 2009 and 2017, to which DFG replied that it currently has no such comprehensive dataset. DFG stated that it is "currently preparing an evaluation of its clinical trials programme. In the framework of this evaluation the data you requested will be collected and analysed, as the outcomes of trials supported by DFG is of high interest including for DFG itself." TranspariMED, an organisation which aims to end evidence distortion in medicine, sees this development as a good opportunity for DFG to check whether and when clinical trials were registered and their results made public. Previous research has shown that nearly a third of German academic trials never make their results public. This not only wastes public money, but also harms patients because it leaves gaps in the evidence base on the efficacy and safety of drugs, medical devices, and non-drug treatments. Due to gaps in German law, there is still no legal obligation to make the results of many German clinical trials public. Read full story Source: TranspariMed, 20 December 2022
  6. Content Article
    Key messages Fall-related fractures can happen on any ward There is only one chance to get it right High quality multi-factorial risk assessment (MFRA) is necessary to ensure important fall risk factors are addressed Accurate post-fall checks support effective care All inpatients should have access to flat lifting equipment to move patients from the floor Inpatients who sustain a femoral fracture should have immediate access to analgesia Improvement activities should focus on fall prevention and post-fall management processes
  7. Content Article
    The report found that the datasets most likely to be identified as influencing change are those which review maternal and neonatal mortality, namely those produced by MBRRACE-UK and HSIB reports. Other key findings include: Recommendations were commonly identified as the most useful thing within reports, particularly by clinical staff Resource and time constraints for quality improvements were commonly cited as barriers, but More than 85% of respondents felt that at least one dataset was influencing quality improvement. The report goes on to make a number of recommendations, including a call for central bodies to develop a single website that signposts to all national maternity reports and datasets, and contains up-to-date guidance on all mandatory reporting requirements.
  8. Event
    The National Comparative Audit of Blood Transfusion is the largest programme of clinical audits of blood transfusion in the world and is funded by NHS Blood and Transplant. It began in 2002 and audits the administration of blood and blood components as well as assessing appropriate use of blood in various clinical settings. It is concluding its work on three National Comparative Audits: 2018 audit of the use of fresh frozen plasma, cryoprecipitate and transfusions for bleeding in neonates and other children 2019 Re-audit of the medical use of red cells 2021 audit of NICE Quality Standard 138 This webinar includes a 40 minute presentation by experts from NCA and SHOT teams. Register
  9. Event
    This one day masterclass, Mr Perbinder Grewal, General & Vascular Surgeon and Human Factors Trainer, will focus on teams working effectively and productively through improving the culture within healthcare organisations. There will be a focus on how safety and culture is perceived by healthcare staff and how culture relates to QI and audit. The outcome of the day is to not only improve safety culture and patient safety but also staff experience and staff engagement. Key learning objectives: Define culture within healthcare. Understand safety culture. Explore culture of quality improvement and audits. Improve civility within teams. Learn how to lead cultural change. All Medical and Non-medical Staff should attend. This masterclass is aimed at Clinical Staff, Team Managers, Senior Management. Register hub members receive 20% discount. Email: info@pslhub.org for discount code.
  10. Content Article
    A year ago, you implemented a new approach to auditing at Barnsley. Can you tell us what prompted it? In healthcare, we tend to measure safety by looking at negatives. The number of falls, the number of category 2 pressure ulcers, the number of adverse events etc. Our whole system is built on it, from local auditing and Datix reporting, to CQC inspections. But counting the number of pressure ulcers for example, doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps keep patients safe. Where did you start? We started with pressure ulcer reduction. Our Tissue Viability team and I looked at the learning from Root Cause Analyses and worked together to create a list of all of the things we can do to help prevent pressure ulcers. Skin assessments, pillow positioning, moving patients etc. If we ticked every box for every patient, would we prevent pressure ulcers altogether (unless the patient doesn’t follow the advice)? I took this list and worked with the digital app company, Perfect Ward to build a simple-to-use auditing tool. It allows us to measure safety by our standards of care and interventions rather than counting negative outputs. If our standards of care are high and a lot of people are still getting pressure ulcers, we have assurance on the standard of care being delivered. How did you implement the pressure ulcers audit? Once we had created the list of standards and preventative measures, we used the app to do an audit of around 35% of patients on each ward. At the start of the project, we found that teams were on average hitting 64% of the standards. The digital app provides a performance rating system, with red with red (less than 70%), amber (greater than 70% but less than 90%) and green (90% or more). The performance of the team against these ratings dictate how we would support each team moving forward. For example, if an audit showed a team to be performing at the lowest level (red), we made a commitment to support them on a weekly basis until they were performing at the highest level (green). How have staff responded? Staff have responded really well. This system provides recognition, and credit where credit is due. It can help staff to feel confident when they are providing high standards of care and to know that they are doing the right thing for the patients. Where there is room for improvement, the Perfect Ward app makes it is easy to see where the gaps in the delivery of interventions exist so they can be tackled. The tissue viability nurses are there to support, coach and to help problem solve. There may be certain interventions that are consistently missed which can sometimes be a sign that the wider organisation needs to help solve the issue. Safety is a shared responsibility, and we need to make sure we have the systems in place to support success. What support have you needed along the way? It’s really important to have passionate people who understand and believe in this approach to auditing. You need to have an Executive Team who are prepared to look at measuring outcomes differently. I’m lucky, our Director and Deputy Director of nursing are very supportive. It’s also important to acknowledge that it is not a silver bullet; change takes time. That can be frustrating for some people who want to see results quickly. It’s taken a year but teams are now hitting on average 94% of the standards set out by the auditing tool, and we are starting to see decreases in category 2 pressure ulcers (per 1000 bed days) since June 2020. What have you learnt? It has been really important to constantly engage staff and build good relationships, to make sure we understand everyone’s competing priorities. The approach has been a great enabler for quality improvement methodology, empowering teams to find their own solutions and really own the results. What’s next? This approach to auditing is not rocket science. It can be used to raise standards of care in most circumstances within health and social care – without focusing on the negatives. We have successfully applied it to both pressure ulcer and falls prevention at Barnsley and just started on nutrition and hydration. In the future I’d like to see it used in other areas, to identify what excellent dementia care in hospitals looks like for example. It could also be used to ensure that staff have a good understanding of the Mental Capacity Act and safeguarding processes. Or to make sure patients are being well-fed. It really is just a blueprint that can be used to raise standards of care, and safety in any circumstance. Final thoughts? I personally don’t like to look at my work as reducing harm. I prefer to look at it in terms of improving the standards of care we give our patients. The difference is important. Photograph of the Tissue Viability Team. Above is an example of a checklist used for pressure sores. The graph above shows the trust average on delivery of the pressure ulcer prevention interventions across adult inpatient wards over a 12 month period. The 'distribution of score' graph above shows the percentages scored across the adult inpatient wards for each month over a 12 month period. This graph shows more areas achieving 90% (or more) and fewer scoring 70% or less as time has progressed.
  11. Content Article
    Some key findings from the audit: Inpatient mortality was 26%. It has reduced from 34% in 2013 and represents the first time that mortality has improved since the first BTS audit in 2010. Compared to the last audit, an increased proportion of patients treated with acute non-invasive ventilation (NIV) had COPD, the indication with the strongest evidence. We saw a decreased proportion of patients who were treated with NIV despite no clearly documented indication. This suggests improved patient selection in line with the evidence base for NIV. 50% of patients treated with NIV started NIV treatment within 60 minutes of the blood gas that defined the need for NIV. Clinician responses indicate a reduced perception of treatment delay in comparison to prior audits. Acute NIV was successful in resolving respiratory acidaemia for 76% of patients treated, in comparison to 69% in the last audit (2013). Only 74% of organisations reported that they have sufficient capacity to deliver the routine acute NIV service. Only 52% of organisations had a nursing lead and 34% had a physiotherapy lead for their acute NIV service.
  12. Content Article
    The findings include: 71% of patients were checked for injury before being moved (up from 69% in 2019) Flat lifting equipment was used for 26% of patients (up from 22% in 2019), and 62% of patients were assessed by a medic within 30 minutes (up from 52% in 2019). The risk factor which was most often assessed was continence, with 74% patients undergoing this component of the MFRA (multi-factorial fall risk assessment). Lying/standing blood pressure was the least often assessed, with 35% getting this assessment. The report makes a number of recommendations, including a call to administer analgesia as soon as a provisional diagnosis of inpatient femoral fracture (IFF) is made, aiming for within 30 minutes of the fall.
  13. Content Article
    This report highlights some key findings. Clinical services 100% of direct medical services were conducting the Clinical Standards Scorecards to ensure the safety of their service provision. However, use of the monthly and quarterly checklists was not as high or as regular. Direct service delivery in a majority of countries audited (5 out of 7) were fully compliant with the Clinical Standards. The average patient satisfaction score was 88%, outlining that in general, the 105 patients surveyed were satisfied with all aspects of service provision within our direct medical services. The report also makes recommendations for improvement related to: Infection prevention and control Morbidity and mortality reviews Clinical referrals Medical standard treatment compliance Clinical triage Infrastructure Human resources for health Pharmacy services Overall compliance to pharmacy standards varies significantly across countries, ranging from 57 to 100%. Compliance with waste management and Medical Incident Reporting (MIR) is generally high (above 80%) across all seven countries. Countries that were able to attend GMT Pharmacy Reference Group meetings on a regular basis had higher compliance scores. The report also makes recommendations for improvement related to: Sourcing medications In-country staff engagement Stock management Medication storage Ensuring pharmacy support at a local level