Safety Resources
To deliver safe health care, clinicians require training in the discipline of patient safety. This includes an understanding of the nature of error in health care, the ability to learn from error, and knowledge of those tools available for improving and monitoring safety.
This resource area offers an introduction to the language commonly used when discussing patient safety. It includes some of the key organisations within the NHS whose remit involves patient safety, commonly used terms and describes those tools used to monitor and improve safety.
Click on below to jump to the relevant section:
Care Quality Commission (CQC) - the health and social care regulator for England www.cqc.org.uk
Centre for Patient Safety and Service Quality (CPSSQ) - CPSSQ comprises a highly specialised set of research groups, working together to improve patient safety and the quality of healthcare services. CPSSQ is part of the National Institute for Health Research http://www1.imperial.ac.uk/medicine/about/institutes/patientsafetyservicequality/
Institute of Health Improvement (IHI) - an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts www.ihi.org/ihi
NHS Institute for Innovation and Improvement - supports the NHS to transform healthcare for patients and the public by rapidly developing and spreading new ways of working, new technology and world-class leadership www.institute.nhs.uk
National Health Service Litigation Authority (NHSLA) - handles negligence claims and works to improve risk management practices in the NHS www.nhsla.com/Channels/
National Institute for Health and Clinical Excellence (NICE) - is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health www.nice.org.uk
National Patient Safety Agency (NPSA) - leads and contributes to improved, safe patient care by informing, supporting and influencing the health sector. www.npsa.nhs.uk They have 3 divisions:
- National Reporting and Learning Service (NRLS, which collects and analyses errors across England and Wales)
- National Clinical Assessment Service (NCAS)
- National Research Ethics Service (NRES)
Scottish Patient Safety Alliance (SPSA) - The Scottish Patient Safety Alliance has been established by NHS Scotland to oversee the development of the Scottish Patient Safety Programme, which aims to steadily improve the safety of hospital care by using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes www.patientsafetyalliance.scot.nhs.uk
World Health Organisation (WHO) Patient Safety – a programme which aims to coordinate, disseminate and accelerate improvements in patient safety worldwide. Each year, WHO Patient Safety delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world www.who.int/patientsafety/about/en/index.html
High Level Enquires (HLE) – enquiries undertaken at a national level that have relevance to the Trust
Never Events - A list of events as set out by the NPSA that should never occur
www.nrls.npsa.nhs.uk/resources/collections/never-events/
Patient safety Walkabout - A routine visit undertaken in a clinical area to provide a ‘snapshot’ of actual practice and safety
Root Cause Analysis (RCA) - offers a framework for reviewing patient safety incidents (and claims and complaints). Investigations can identify what, how, and why patient safety incidents have happened. Analysis can then be used to identify areas for change, develop recommendations and look for new solutions. www.nrls.npsa.nhs.uk/resources/collections/root-cause-analysis
SBAR (Situation - Background - Assessment - Recommendations) - SBAR is an easy to remember mechanism that you can use to frame conversations, especially critical ones, requiring a clinician's immediate attention and action. It enables you to clarify what information should be communicated between members of the team, and how. It can also help you to develop teamwork and foster a culture of patient safety.
The tool consists of standardised prompt questions within four sections, to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition.
Download posters for use in your ED (with thanks to Cambridge University Hospitals NHS Trust):
For more information on SBAR: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html
Serious Incident or Serious Untoward Incident (SI / SUI) - reporting is designed to inform Strategic Health Authorities and the Department of Health about incidents that require urgent attention. They are not necessarily patient safety incidents
Crisis Resource Management (CRM) - can be defined as a management system which makes optimum use of all available resources - equipment, procedures and people - to promote safety and enhance efficiency. Originally used in aviation but increasingly utilised in healthcare
Clinical Negligence Scheme for Trusts (CNST) - The Clinical Negligence Scheme for Trusts handles all clinical negligence claims against member NHS bodies where the incident in question took place on or after 1 April 1995 (or when the body joined the scheme, if that is later). Membership of the scheme is voluntary www.nhsla.com/Claims/Schemes/CNST/
Essentials of Patient Safety - Written by Prof Charles Vincent, a short verion is available to download for free. The topics addressed include the evolution of patient safety; the research that underpins the area, understanding how things go wrong, and the practical action needed to reduce error and harm and, when harm does occur, to help those involved. The main book covers these topics in more depth and a number of additional topics such as measurement, safety culture, design, safety campaigns and safe organisations. http://www1.imperial.ac.uk/medicine/about/institutes/patientsafetyservicequality/cpssq_publications/
Failure Mode and Effects Analysis (FMEA) – a methodology for analyzing potential reliability problems. See:
FMEA: A model for reducing medical errors
M Chiozza, C Ponzetti
Clinica Chimica Acta
Volume 404, Issue 1, 6 June 2009, Pages 75-78
Global Trigger Tool (GTT) – an easy to use tool that supports a structured case note review to identify harm events. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using triggers to identify possible adverse events. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. See:
Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009 (Available on www.IHI.org)
NHS Evidence - Provided by NICE, NHS Evidence is a new service which will develop, enhance and expand the services that were previously provided by the National Library for Health (NLH). http://www.evidence.nhs.uk
National Service Frameworks (NSF) - cover some of the high priority conditions and key patient groups. They
- set clear quality requirements for care based on the best available evidence of what treatments and services work most effectively for patients, and
- offer strategies and support to help organisations achieve these
Patient Safety First - A national campaign that aims:
- to ensure the safety of patients is everyone’s highest priority
- to reduce harm by changing practise in specific areas
It is sponsored by the NHS Institute for Innovation and Improvement, the NPSA and the Health Foundation. www.patientsafetyfirst.nhs.uk
Plan, Do, Study, Act (PDSA) - The PDSA cycle tests a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).
www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act%20(PDSA)%20Worksheet
Patient Safety Alert (PSA) - Through analysis of reports of patient safety incidents, and safety information from other sources, the National Reporting and Learning Service (NRLS) develops advice for the NHS that can help to ensure the safety of patients
Advice is issued to the NHS as and when issues arise, via the Central Alerting System in England and directly to NHS organisations in Wales. Alerts cover a wide range of topics,. Types of alerts include Rapid Response Reports, Patient Safety Alerts, and Safer Practice Notices. www.nrls.npsa.nhs.uk/resources/type/alerts/
Reporting incidents - From 1 April 2010 it became mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process. To avoid duplication of reporting, all incidents resulting in death or severe harm should be reported to the National Reporting and Learning Service (NRLS), who will then report them to the Care Quality Commission.
Report a patient safety incident here:
Guidance on reporting incidents in Scotland is available here:
http://www.clinicalgovernance.scot.nhs.uk/section5/how.asp
Other sections in this area:
- Safer Care Introduction - introduction to safety and the College's role
- Safety News - latest developments in patient safety
- Safety Alerts - latest reports from the National Patient Safety Agency and Medicines and Healthcare products Regulatory Agency
- Safety in your ED - CEM resources for developing patient safety in your ED
- Safety Events - find events where you can learn more