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Showing results for tags 'NRLS'.
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News Article
NHS hospitals ordered to remove drug after mistakes led to two baby deaths
Patient Safety Learning posted a news article in News
All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug. A national safety alert was issued following several incidents, including two deaths of babies, in which patients were inadvertently given a dose of sodium nitrite – which is used as an antidote to cyanide poisoning – rather than sodium bicarbonate. The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers. Now hospitals have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product. The drug should only be available in emergency departments and may have been supplied to medical wards by mistake. There are an estimated 237 million medication errors in the NHS every year – with a third linked to packaging and labelling. Read full story Source: The Independent, 9 August 2020 -
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News ArticleMore than half of all incidents resulting in death reported by health boards in Wales came from troubled Betsi Cadwaladr. The 53% figure from a Welsh Government safety report came to light during First Minister Questions in the Senedd yesterday. Plaid Cymru Leader Adam Price said there had been “an alarming rate” of patient safety incidents in the Betsi Cadwaladr University Health Board area and that between December 2018 and November 2019 there were 40 incidents resulting in death registered within Betsi. Between November 2017 and November 2019 there were 520 incidents within Betsi that resulted in death or serious harm - higher than all the other health boards in Wales combined. Mr Price questioned whether there is an issue with Betsi itself, or whether there is an issue of "under-reporting of serious incidents" in the rest of Wales. Defending the figures, the First Minister said that reporting incidents and learning from them has become part of the culture of a health board that they “want to see everywhere in Wales”. Read full story Source: North Wales Live, 29 January 2020
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News Article
NHS is ‘losing its memory’ warns new report on patient safety alerts
Patient Safety Learning posted a news article in News
In a report published today, AvMA, the charity Action Against Medical Accidents, 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, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, 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. David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived." “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections. Read full story Source: AvMA, 28 January 2020 -
Community PostDear All Please excuse my ignorance, especially if I am failing to see or understand something that is so glaringly obvious! However, I wondered if any of you, my esteemed colleagues, would be able to assist me with a conundrum that I currently face: Number of incidents occurring per 1,000 bed days My questions: What does this actually mean, and how is this useful exactly? How do you know if the sum of a bed days calculation is good or bad? How can this sum be used to quantify/understand incidents that occur within an outpatient setting (or a setting that does not involve bed days)? For example, if we say that an organisation has 5,910 incidents and a bed days figure of 171,971, we would then need to calculate 5,910 / 171,971 x 1000 = 34.36. As the NRLS uses the 'metric', incidents by 1000 bed days, to write a report which includes this sum for your organisation, and that of your "cluster" (other organisations that are 'supposedly' similar to yours), what does this sum actually signify and how can this be used to try and compare yourself to other service providers? Regards Faizan
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Content ArticleKey recommendations from the report Treating clinicians should ensure that all people with ocular hypertension or suspected or diagnosed glaucoma are monitored within the monitoring intervals outlined in the NICE glaucoma guideline, and none of these monitoring appointments should be delayed or cancelled.
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News Article
Deaths of 4,600 NHS patients linked to safety incidents
Patient Safety Learning posted a news article in News
Safety incidents at hospital, mental health and ambulance trusts were linked to more than 4,600 patient deaths in the last year, data shows. The types of patient safety issues recorded by the National Reporting & Learning System (NRLS), which compiles NHS data, include problems with medication, the type of care given, staffing and infection control. In total 4,668 deaths were linked to patient safety incidents, of which 530 deaths specifically linked to mental health trusts and 73 to ambulance trusts. Guidance accompanying the data from the NRLS, which was set up in 2003, states deaths are not always “clear-cut” and cannot always be attributed to patient safety incidents. However, under the “degree of harm” section recorded on the system, there were 4,688 cases listed as death. In total, 4,356,277 reports of patient safety incidents were reported between November 2018 and October 2019. They are described as issues where unintended or unexpected incidents which could have – or did – lead to harm of a patient under the care of the NHS. Other safety incidents had links to consent, paperwork, facilities, and in some cases patient abuse by staff or a third party. Read full story Source: The Guardian, 9 December 2019 -
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