Through its review of recorded patient safety events, the National Patient Safety Team identified issues where the diagnosis of hyperammonaemia (raised ammonia levels in the blood) in children was delayed due to issues preventing the timely analysis of blood samples.
The team’s analysis of incidents reported to the National Reporting and Learning System (NRLS) found delays had been caused by blood samples not being analysed in a timely manner, samples being discarded due to being haemolysed, and a miscommunication in the given results. This often meant repeat blood samples were needed before a diagnosis could be made, risking delays in the commencement of urgent treatment.
As a result, the Royal College of Pathologists agreed to further promote its National Metabolic Biochemistry Network best practice guidelines/standards for hyperammonaemia, which state haemolysed samples should be analysed and reported on with a comment that the results will show a higher level due to this and a repeat sample needed, but crucially gives a result to enable treatment to be started.
The college also issued a Patient Safety Bulletin that included a recommendation that raised ammonia results for babies and children are telephoned directly to the relevant consultant on call and not the ward.
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.