- For Professionals (Shop Floor)
- Clinical Guidelines
- Clinical Standards
- Clinical Audit
- Professional Standards
- Consultant Working and Job Planning
- Advisory Appointments Committees
- Middle Grades and Locum Consultants
- Service Configuration
- Service Reviews
- Further Resources
- Francis Inquiry Report
- Quality in the Emergency Department
- Creating satisfaction and maintaining wellbeing in EM
- 10 priorities for Emergency Medicine
- Safer Care
Every two months the National Reporting and Learning Service (NRLS) shares key risks emerging from review of serious incidents reported by the NHS.
The NRLS’s Reporting and Learning System (RLS) now holds over 3.5 million patient safety incidents, reported from across the NHS in England and Wales. In this large database, it may be difficult to identify the most pressing issues, given the ‘noise to signals’ ratio.
The NRLS reviews each reported incident of patient death or serious harm – around 350 every week. These are then prioritised for action, based on evidence from the wider incident database, litigation data and clinical input.
Around 10 a year result in Rapid Response Reports (RRRs) which require actions by trusts to reduce risks to patients. But there is much rich learning over and above those issues that result in RRRs.
Many of these topics are still being explored by the NPSA and other organisations.
It is really important that organisations continue to report patient safety incidents in the usual way through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.
Issue 8 published February 2012
Latest topics include:
- Diagnosis of death after cessation of cardiopulmonary resuscitation
- Risk of harm from CPM syndrome following rapid correction of sodium
- Risk of skin-prep related fire in operating theatres
- Risk of harm following gastric bypass
- Recognising and instigating prompt treatment for necrotising fasciitis
- Prevention of Harm with Buccal Midazolam
- Patient safety issues related to gastrostomy
See also RRRs relevant to Emergency Medicine