Through its review of recorded patient safety events, the National Patient Safety Team identified an issue where emergency department clinicians may not always have access to the latest version of a triage assessment tool, which could lead to poorer patient outcomes.
The team received information that older versions of the triage assessment tool gave different treatment priorities to that of newer versions, in particular regarding adult and paediatric sepsis.
As a result, working with NHS X and NHS Digital, regional NHS teams brought this issue to the attention of NHS trusts with emergency departments. These trusts were also asked to check that a robust critical upgrade process exists to ensure that the latest versions are in use and that subsequent editions will be implemented in a timely manner.
The team also engaged with the Royal College of Emergency Medicine, who wrote to their safety leads asking them to check what versions are in use in their organisations, and to ensure systems are in place to confirm upgrades are installed.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this 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.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.