Through its core work to review patients safety events recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified an issue with oxygen hoses becoming disconnected from transport ventilators. An issue raised in a […]
NHS England today welcomes the Berwick Report into NHS patient safety, and pledges further action to help make the NHS the safest healthcare system in the world. Professor Don Berwick, renowned international expert in patient safety, was asked by the Prime Minister to carry out the review following the publication of the Francis Report into […]
Since the publication of this blog Dr Mike Durkin has left NHS England. By Dr Mike Durkin, NHS England director of patient safety: Patient safety has been a key priority in NHS England’s first year. There can be no question that it should always be of paramount importance to everyone working in the NHS, but […]
A new alerting system launched today by NHS England will ensure warnings of potential risks to the safety of patients can be developed much more quickly and be rapidly disseminated right across the NHS. The new National Patient Safety Alerting System (NPSAS) will ensure warnings of emerging risks can be rapidly issued following their identification […]
Through its review of recorded patient safety events the National Patient Safety Team identified an issue related to retention of bone cement following hip surgery. An incident described an elderly patient returning to theatre to remove unintentionally retained bone cement, following a hip replacement procedure for a fractured neck of femur. Bone cement is used […]
Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified issues where ventilators had been left in standby mode. The team reviewed a Serious Incident report describing a […]
Through its review of recorded patient safety events, the National Patient Safety Team identified issues relating to the ingestion of toilet gel discs. An incident report described a small child who ingested a toilet gel disc. Hospital staff sought advice from Toxbase® (the online poisons information database) which stated the product was not toxic and […]
This alert temporarily advising against the use in the home of birthing pools with built-in heaters and recirculation pumps, potentially filled up to two weeks in advance of the birth.
The events at Mid-Staffordshire Hospitals sent shock waves throughout the NHS and the general public, and have focussed the minds of all of us who work in the NHS, on the fact the job of assuring and improving the safety of our patients is never finished. The Berwick Report, published today, clearly identifies the importance […]
Thousands of ambulance crews across the country will be provided with body cameras as part of an NHS crackdown to reduce attacks on staff. The introduction of the cameras comes alongside data that 3,569 ambulance staff were physically assaulted by the public last year – 30% more than five years ago. Following successful trials in […]