This page is part of the wider ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ set of webpages.
Several previous alerts set requirements for specific clinical procedures only to be undertaken by staff trained and competent to do so, or for specific medications only to be prescribed, dispensed, or administered by staff trained and competent to do so. This is now considered a universal requirement that applies to all clinical procedures and all medications, rather than only those specified in previous alerts.
Professional regulators and educational bodies provide detailed current guidance on what are considered core and advanced clinical competencies. Organisations and healthcare professionals should reference these sources rather than previous alerts.
Some previous alerts set requirements for ‘ongoing audit’. The intention was that if undertaking improvement work on a large-scale and challenging issue, measurement would identify whether efforts were leading to positive changes in processes or outcomes.
Many sources of data are now available that reduce the need for audit via manual case record review. All organisations should have patient safety improvement programmes for their key local patient safety challenges, including measurement approaches in line with the National Patient Safety Strategy, but they should prioritise their current local challenges rather than any specific topic identified in past alerts as requiring ‘ongoing audit’.
Several past alerts set out requirements for organisations to produce local policies or protocols. It is essential that procedures are clearly documented, reflect local circumstances, and describe safe practice that all practitioners can reasonably be expected to achieve. It is equally essential that these documents are written in a manner that makes them easy to use by frontline staff when required and are easily accessible.
Patient safety incidents commonly result where procedures are absent or incomplete, or where staff do not follow written procedures due to a lack of awareness, insufficient knowledge, or because it is not practical to comply with them or the value of following them has not been made clear.
There is an expectation that all organisational policies and procedures are regularly updated and therefore remain pertinent to current issues. Organisations should maintain this process of comprehensive review and updating of all local policies and procedures, rather than prioritising any specific topic that in past alerts required the development of local policies and procedures.
Some past alerts emphasised the value of having ‘kits’ containing all required equipment/medication/easy reference guides to respond to specific emergencies such as hyperkalaemia or status epilepticus. The principle remains sound, but organisations should apply it to all emergencies likely to be locally encountered, rather than prioritising any specific topic that in past alerts required the development of ‘kits’.
Risk assessment (identifying the likelihood and severity of any threat to safety and taking action to reduce it) is an important part of overall safety governance. Organisations should focus on overall systems of risk assessment rather than prioritising any topic that in past alerts required a specific risk assessment.
Go back to the main ‘Aspects of previous patient safety alerts that should inform broader local safety initiatives’ webpage.