Quality News - All Comments

re: Patient Safety and NHS Trusts – Does the future look bright?

Angela — Thu, 18 Feb 2010 11:43:35 GMT

This article seems to reveal a real dichotomy in the approach to patient safety. Why, when so much emphasis and pressure is placed on reporting issues to the NPSA, are there not equal measure taken to ensure that action is taken from the learning process? Surely it makes sense that if we action the steps that have been found to reduce the risk of harm, that the pressure will be reduced at the reporting end as there will be fewer incident to report!

To my mind the requirement to take action on an NPSA Alerts should at least be equal to the requirement to report a new incident, because if this isn’t the case the situation will never improve.

In the NHS today with so many demands on the Governance Team, it is not hard to see why there is a struggle to keep on top of everything that needs to be done and as such Trust will of course need to turn to risk assessment to decide what comes first. Perhaps is the AcMA’s recommendation ‘that boards should be required to have patient safety as an agenda item at each meeting’ will help to push this item on to the risk register so that it can receive the attention it deserves.

Fortunately for our customers the tools to manage the communication and action management required to effectively manage NPSA Alerts are there today.

re: Patient Safety and NHS Trusts – Does the future look bright?

WarwickA — Thu, 18 Feb 2010 11:31:54 GMT

I would hazard a guess that most Trusts don't have a robust system to ensure that the process to deal with these is followed. When I first heard of this even though it is so important I thought “It’s just yet another ton of red tape for the NHS to deal with”, but when you realise the small number of alerts involved I think it is even more shocking.

As outlined in the article by Richard Vize,

“Safety alerts are not a blizzard of paper; there were just 53 in the six years covered by the study, affecting both hospitals and primary care. They highlight risks across the spectrum of treatments, from drug doses to feeding tube insertions”.

On Channel 4 News on Tuesday night they said the worst offender had over 30 alerts that had not been dealt with within the permitted timescale and this information is only accessible through The Freedom of Information Act. I would have thought this information might be quite useful when deciding which Trust’s services you wanted to use!!!

Richard Vize commented,

“Safety standards will be raised by transparency, enforcement and patient-centred care. Action Against Medical Accidents should not have needed to exploit the Freedom of Information Act to get this data into public view; NHS organisations should be compelled to publish their failure or success in compliance. Exposure to the ire of the local press gets results”.

What amazes me is how simple and inexpensive setting up a system to demonstrate this process would actually be and why it hasn’t already been done? What’s the point in having a system that reports incidents to the NPSA but doesn’t help the troops on the ground to rectify a situation when an incident occurs or as is now clear the actions that need to be taken when the NPSA feeds the information back down, surely this should all be integrated?

Systems can provide visibility, transparency and reporting that are not there to highlight failings but more to identify areas of weakness and define a process of continuous improvement to rectify this. Crucially, demonstrating what actions have been taken to ensure these incidents don’t happen again. Taking this approach would not only put patient safety first but may even restore a bit of the public’s confidence if they could see what steps their Trust was taking to ensure their well being.

I wonder whether the NHS Trust’s will look to act on this information now voluntarily, or wait to be dragged kicking and screaming when the regulator gets some proper teeth!

Patient Safety and NHS Trusts – Does the future look bright?

Quality News — Thu, 18 Feb 2010 09:11:38 GMT

After the publication of a report on 16 th February by Action Against Medical Accidents (AvMA) - Adding

re: Reap the Rewards for improving Patient Safety Incident Stats?

Gregor McCall — Fri, 22 Jan 2010 09:26:01 GMT

This has also been identified as an area for improvement within Care Homes

Recently published research commissioned by the DH as part of the patient safety programme identified considerable scope for improvement of prescription, dispensing, administration and monitoring of medicines in care homes. The study’s authors recommend clear local leadership and improved inter-professional communication.

In summary, the main findings were:

•residents (mean age 85 years) were taking an average of 8 medicines each

•on any one day 7 out of 10 patients experienced at least one medication error

•whilst the mean score for potential harm was relatively low, the results did indicate opportunity for more serious harm.

The full text version of the research can be downloaded here: http://bit.ly/4VlDw4

CQC will be carrying out their own review and their existing guidance is available on their website

www.cqc.org.uk/.../newsstories.cfm

Other useful guidance includes the Royal Pharmaceutical Society of Great Britain 2007 – The Handling of Medicines in Social Care

re: Reap the Rewards for improving Incident Stats?

AmandaO — Wed, 20 Jan 2010 15:25:27 GMT

I too read the article from the BBC website yesterday regarding the drug treatments to children. Being a mother and also just having my appointment for my child to receive her jag for Swine Flu, this area is of a concern to me. As parents we presume that any dosage provided by our doctors for our children are tested, but from reading this article it definately seems that this is not always the case, and in most cases the dosage is actually determined by the Doctor based on experience of the doctor, child age, weight etc.

If Pharmacists had a proper tool to use that would allow them to quickly report any errors/near misses then this would allow the judgement on dosage to come from a large knowledge base as well. This would certainly make me feel a little easier about the choices I am making for my child with her treatments.

re: Should quality goals determine financial strategies within the NHS?

Bubonic — Sun, 13 Dec 2009 13:40:18 GMT

Laboratories in Greater Glasgow & Clyde are under the same cost saving exercises and have already re-organised / centralised some services with significant savings whilst being committed to maintaining quality.

The human element is critical here. Undue staff pressures for example can lead to sickness (stress) which would only exacerbate the situation.

Fundamental to quality is staff buy-in and it's never more important when savings require to be made. Helpful in this process is a policy of no redundancy which has been at the forefront of GG&C thinking to date.

re: Gael’s partner in Ireland attends prestigious Healthcare conference

AlanH — Fri, 11 Dec 2009 11:32:06 GMT

Good to see HCI with such a high profile at this well attended event.

re: Risk Management - creating a culture of safety within the NHS

Bubonic — Mon, 23 Nov 2009 23:17:22 GMT

The NHS endeavours to become an organisation with a memory. Learning from its mistakes and the mistakes of others towards improving patient safety and the elimination of risk.

Between 70 & 80% of all medical diagnoses are said to be laboratory based and the Medical Laboratories of Greater Glasgow and Clyde use Q-Pulse to assist in delivering quality managed services accredited to international standards giving confidence in laboratory reportables.

Risk Management - creating a culture of safety within the NHS

Quality News — Wed, 18 Nov 2009 09:36:10 GMT

In today’s Health Service Journal, an article on risk management within the healthcare sector states

re: Corporate Manslaughter Act: establishing a culture of safety with Q-Pulse

LornaE — Thu, 10 Sep 2009 10:20:39 GMT

Hi Mike,

Thanks for your comment, very interesting, has anyone else had to change the way they work, or added any more checks etc since the Act came into force?