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 timely administration of HIV prophylaxis in new-borns.
With appropriate anti-retroviral treatment of mothers during pregnancy and labour, and avoidance of breast feeding, the risk of transmission of HIV from mother to baby is reduced from 40% to <0.1%. Management of infants born to HIV-infected mothers requires a coordinated multidisciplinary team approach.
A detailed care plan for the infant should be documented in the mother’s pregnancy record and include the need to plan for the baby to receive anti-retroviral therapy within four hours of birth.
A review of the NRLS demonstrated examples of limited understanding of the need to plan ahead to ensure antiretroviral medication is administered to babies in a timely manner. In particular, issues around availability of medication and communication of multidisciplinary care plans were identified.
Via the Medication Safety Officer network, whose members represent individual healthcare providers across the NHS, and the maternity and neonatal safety champions, maternity and neonatal leads were asked to work with pharmacy colleagues to agree robust local processes to ensure these medicines are always available and administered in a timely manner providing maximum protection to new-born babies.
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.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. 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.