Welcome to the Royal College of Emergency Medicine's Safety Resources hub. Here you will find information and resources about alerts, safety resources, safety in the Emergency Department and safety events.
+ What is Patient Safety?
Patient Safety is the avoidance of unintended or unexpected harm to people during the provision of healthcare.
The College has established a Safer Care Committee which is undertaking the following:
To see the terms of reference and committee members e-mail safety@rcem.ac.uk
+ RCEM Safety Flashes
Click on the links below for the latest information.
Click on the link below for the latest information.
Click on the link below for the latest information.
The Healthcare Safety Investigation Branch (HSIB) conducts independent investigations of patient safety concerns in NHS-funded care across England. HSIB aims to improve safety through effective and independent investigations that don’t apportion blame or liability. Investigations identify the contributory factors that have led to harm or have the potential to cause harm to patients. The recommendations aim to improve healthcare systems and processes in order to reduce risk and improve safety.
This page has links to recent flashes on equipment faults, high risk procedures etc, as well as other safety organisations.
Please contact safety@rcem.ac.uk if you hear of additional topics that should be on this page.
See all RCEM issued safety newsflashes in the tab below.
The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care.
Links to NHS England, MHRA and Public Health England patient safety alerts can be found below:
All Medical Device Alerts (MDA) can be viewed on the MHRA website here. Selected MDAs sent by the MHRA for circulation to RCEM members are– listed below:
+ Labelling blood transfusion samples from unknown patients
Is your organisation compliant with national guidance for the labelling of blood transfusion samples from unknown patients?
Unidentified patients in the ED are at high risk of transfusion errors due to misidentification. The British Committee for Standards in Haematology recommend that as a minimum, in an unknown patient requiring a blood sample for transfusion the following should be used.
The Safer Care Committee ask that senior teams in the ED review their local policies to ensure they are compliant and the appropriate steps have been taken to minimise the risk of incorrect transfusion in unknown patients.
26 September 2014
The College is issuing a safety alert following an inquest into the death of a patient after a chest drain was inserted into the wrong side. A number of factors specific to the ED were shown to have contributed to this never event; failure to identify an incorrectly labelled chest x-ray, a failure to examine the patient prior to the procedure, a failure to review all chest x-rays and misinterpretation of the chest x-ray reviewed.
Senior teams within EDs are asked to reflect on the possibility of such an event occurring in their own department and ensure they have done all that is possible to reduce the risks associated with this procedure. The safer care committee has previously prepared guidance regarding never events but also refer you to the NRLS Rapid Response Report of May 2008 which addresses the risks associated with chest drain insertion.
Would you consider ingestion of a button battery if a child were to present with a haematemesis?
The modern family home is likely to be littered with multiple devices and toys using button batteries. These are liable to be swallowed by small children and can present in a variety of ways including haematemesis.
Following a recent adverse event a Coroner has issued a regulation 28 notice which highlights the need for staff to be aware of the need to exclude ingestion of a button battery as a cause for upper GI bleeding in young children. This should occur even in the absence of a history of ingestion. Being aware of this presentation and undertaking the appropriate imaging is critical in ensuring the right management of such patients.
Further information is available at the Toxbase website (for health professionals only).
Would you recognise the signs of a patient suffering from an Addisonian crisis?
Fatal but avoidable Addisonian crisis is the second most common cause of death in patients with known Addison’s disease, accounting for 15% of deaths in patients with this disease.
It has recently been highlighted to NHS England that Patients continue to die because of a failure to recognise this condition and ensure patients receive appropriate steroids.
All staff working in the ED need to be aware of the how to avoid precipitating an adrenal crisis. See more here
What is the risk of intracranial haemorrhage in patients on warfarin who sustain head injury?
Although not a formal risk factor in NICE guidelines – there is clearly an increased risk which requires additional thought in the management of these patients. A recent “adverse event” review in Northern Ireland confirms the need to prioritise these cases within the ED; and any delay in assessment; investigation; and treatment of these patients should be avoided. Early CT scanning of all head injured patients on warfarin (irrespective of INR and GCS) appears to be clinically appropriate, with early reversal of INR to be considered in the balance of risk/benefit for the individual patient. Prothrombin complex concentrate should be rapidly available in the ED and be administered promptly when indicated.
With a normal initial evaluation normal initial CT and INR<3, the risk of delayed haemorrhage is <1%. A period of clinical observation in hospital for these patients may not be required but patients must have clear instructions to return. Prudence is advised in the management of head-injured patients on clopidogrel or novel anticoagulants. Insufficient evidence exists at present to provide robust specific clinical advice for these patients.
NICE guidance (updated Jan 2014) reflects the clinical justification for liberal use of CT in patients on warfarin.
Recent BestBETs articles also succinctly summarise the issues:
The first report from the Chief Coroner on Reports to Prevent Future Deaths (PFD) covering the period from 1 April to 30 September 2013 has been published.
Under Schedule 5 paragraph 7 the coroner has a statutory duty to issue a report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. Responsibility for the Reports transferred from the Ministry of Justice to the Chief Coroner on 1 April 2013. During this period, Rule 43 Reports were replaced by PFD reports on the implementation of the Coroners and Justice Act 2009 (the 009 Act), which came into force on 25 July 2013.
These PFD reports provide an opportunity to improve safety across all Emergency Departments as it is likely the events described will or could have occurred elsewhere. Senior teams should use this information to prospectively review local processes in order to reduce the risk of a similar incident occurring in their department.
In total 244 reports were issued in this period; 42 appear to be related to Emergency Medicine or the Emergency Departments. The key themes were:
More detail regarding individual circumstances can be obtained here.
Have you done all you could do to reduce the risk of a never event occurring in your ED?
Senior teams need to ensure they have done all that is possible to understand the possible risks in their ED and take steps to mitigate that risk. The occurrence of a never events is one risk where simple changes are likely to help reduce the opportunity for this to happen. A recent publication from NHS England focused on the surgical never events. Many of their recommendations are applicable to the ED.
The Safer Care Team has previously prepared a guide which highlights the Never Events that could occur within your Emergency Department. This guide identifies events that should never happen but if they do should always be reported and fully investigated to identify learning.
This can be found further below.
2 July 2014
Does your ED have all the necessary equipment to resuscitate a neonate?
All EDs need to stock readily identifiable and available equipment for the resuscitation of babies down to the size of 1.5kg. This must include standard airway, breathing and circulation equipment of the appropriate size, umbilical catheters, and a heat source.
The following links can assist you in accessing guidance:
Do you have an idea about how to make care safer in your ED?
Last month the Secretary of State launched a new campaign to make the NHS the safest healthcare system in the world. Read more about the campaign at www.signuptosafety.org.uk
Sign up and give your ideas to your Trust – make a difference today!
Should you have any feedback or would like to share any ideas with the College, please email:safety@rcem.ac.uk
+ Clinical Governance & Patient Safety Groups
The resources have been produced to help local clinical governance and safety teams in creating a framework for addressing patient safety. The templates can be adapted as necessary.
Never Events are incidents which are considered unacceptable and eminently preventable. The Safer Care Committee has prepared a guide which highlights Never Events that could occur within your Emergency Department. It proposes examples of how to mitigate the risk of these happening and relevant NPSA Alerts and resources.
If you have implemented any other mitigation not included in this guide please do let us know by emailing: safety@rcem.ac.uk
For further information about Never Events please visit the Department of Health and NHS England websites:
The following organisations have key responsibilities relating to the promotion of patient safety.
Emergency Medicine doctors may wish to consult these to keep up to date with developments in safer emergency care.
Care Quality Commission (CQC) – CQC is the health and social care regulator for England.
Centre for Patient Safety and Service Quality (CPSSQ) – CPSSQ comprises a highly specialised set of research groups, working together to improve patient safety and the quality of healthcare services. CPSSQ is part of the National Institute for Health Research.
Institute of Health Improvement (IHI) – an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts.
National Health Service Resolution (NHSR) – handles negligence claims and works to improve risk management practices in the NHS.
National Institute for Health and Clinical Excellence (NICE) – is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.
National Patient Safety Agency (NPSA) – leads and contributes to improved, safe patient care by informing, supporting and influencing the health sector.
They have 3 divisions:
Scottish Patient Safety Alliance (SPSA) – The Scottish Patient Safety Alliance has been established by NHS Scotland to oversee the development of the Scottish Patient Safety Programme, which aims to steadily improve the safety of hospital care by using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes www.patientsafetyalliance.scot.nhs.uk
World Health Organisation (WHO) Patient Safety – a programme which aims to coordinate, disseminate and accelerate improvements in patient safety worldwide. Each year, WHO Patient Safety delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world.
Manchester Triage System – Update letter – March 2021
Second victims are health care providers who are involved in an unanticipated adverse patient event, in a medical error and/or become victims in the sense that they are traumatised by the event. The Safer Care Sub-committee has prepared a guidance document for supporting Emergency Department colleagues who experience such events. This guide advocates key recommendations for individuals and the senior team within the Emergency Department:
The Safer Care Sub-Committee promotes training materials which address patient safety. Within this page you can find training materials which address safer patient care.
The Francis Report is essential reading for all clinicians working in Emergency Departments and has important recommendations for patient safety.
The Safer Care team have developed the following resources to support safety in the wake of the Francis review.
The Francis Report is mandatory reading for all clinicians working in Emergency Departments. Drs Ruth Brown and Sue Robinson have written ‘The Francis Report: a call to arms,’ published within the Emergency Medicine Journal. In this article they advocate that the Francis report serves as a call to arms for ED staff to stop normalising the abnormal and tolerating substandard care, to respect and protect our patients and hold our leaders, and ourselves, to account.
View the Francis Report
The Francis report has many recommendations for organisations as a result of the enquiry. The College has developed this checklist for Clinical Directors of the Emergency Department – taking the most relevant recommendations and identifying key actions for clinical leaders of emergency departments. While the list is not exhaustive it is meant as a handy guide to action that might usefully be taken in the first instance.
View the Francis Report recommendations.
The College has prepared a statement for Fellows and Members on the Francis Inquiry Report outlining what the report is and why it is important for Emergency Medicine. This document also acts a guide to challenging occurrences of poor care.
View the Statement for Fellows & Members on the Francis Inquiry Report
The Berwick report is essential reading for emergency medicine practitioners. It identifies changes that could help the English NHS become safer and more patient-centered whilst making numerous recommendations to help protect patients.
Read the recommendations from Professor Don Berwick and the National Advisory Group on the Safety of Patients in England – Berwick review into patient safety.
Non-technical skills (NTS) have a vital role to play in Emergency Medicine practice. There is increasing awareness that a clinician must not only possess good technical skills but should also be proficient in a variety of interpersonal and cognitive skills in order to optimise patient care. Non-technical skills reduce the opportunity for human error and enhance risk management both of which are known to improve patient care. The College has prepared a Non-technical Skills-Top 10 Tips as a guide on how to maximise emergency physician’s non-technical skills for the benefit of patients and staff.
The Safer Care Committee has developed a new checklist for integrating safety into your Emergency Department. This allows you to assess how well you integrate and consider safety in your departmental activities and makes suggestions for which staff need to be involved.
There have been cases that were the subject of a Coroner’s rule 43 report to the Secretary of State. Both of these involved the system for reporting serious and potentially fatal unexpected findings on radiological imaging. The Safer Care team have prepared guidance for Emergency Teams on reviewing radiological imaging.
The Safer Care Team recommend that Emergency Medicine doctors utilise these tools, resources and systems when considering patient safety.
CRM can be defined as a management system which makes optimum use of all available resources – equipment, procedures and people – to promote safety and enhance efficiency. Originally used in aviation but increasingly utilised in healthcare.
The Clinical Negligence Scheme for Trusts handles all clinical negligence claims against member NHS bodies where the incident in question took place on or after 1 April 1995 (or when the body joined the scheme, if that is later). Membership of the scheme is voluntary.
Written by Prof Charles Vincent, a short version is available to download for free. The topics addressed include the evolution of patient safety; the research that underpins the area, understanding how things go wrong, and the practical action needed to reduce error and harm and, when harm does occur, to help those involved. The main book covers these topics in more depth and a number of additional topics such as measurement, safety culture, design, safety campaigns and safe organisations.
See Essentials of Patient Safety.
Failure Mode and Effects Analysis (FMEA) – a methodology for analysing potential reliability problems. See:
M Chiozza, C Ponzetti
Clinica Chimica Acta
Volume 404, Issue 1, 6 June 2009, Pages 75-78
An easy to use tool that supports a structured case note review to identify harm events. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using triggers to identify possible adverse events. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. See:
Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009 (Available on www.IHI.org)
Provided by NICE, NHS Evidence is a new service which will develop, enhance and expand the services that were previously provided by the National Library for Health (NLH).
The National Service Frameworks cover some of the high priority conditions and key patient groups. They work to:
See more in the National Archives.
Patient Safety – 10 things NHS Trusts should already be doing
This document from the Centre for Reviews and Dissemination of the NIHR and University of York highlights 10 key things which should be undertaken by Trusts to promote patient safety.
Patient Safety First is a national campaign that aims:
It is sponsored by the NHS Institute for Innovation and Improvement, the NPSA and the Health Foundation.
The PDSA cycle tests a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).
Through analysis of reports of patient safety incidents, and safety information from other sources, the National Reporting and Learning Service (NRLS) develops advice for the NHS that can help to ensure the safety of patients.
Advice is issued to the NHS as and when issues arise, via the Central Alerting System in England and directly to NHS organisations in Wales. Alerts cover a wide range of topics. Types of alerts include Rapid Response Reports, Patient Safety Alerts, and Safer Practice Notices. See more here
From 1 April 2010 it became mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process. To avoid duplication of reporting, all incidents resulting in death or severe harm should be reported to the National Reporting and Learning Service (NRLS), who will then report them to the Care Quality Commission. Report a patient safety incident here.
This report from the Point of Care Foundation shows that the way healthcare staff feel about their work has a direct impact on the quality of patient care as well as on an organisation’s efficiency and financial performance. This report is available here.
The RCEM Safer Care committee had produced a poster that lists simple steps that everyone can take to improve patient safety and raise awareness of patient safety. Please download and display in your ED. See here.
Ensure you are up to date with the latest Clinical Guidelines, which impact you and your patients by clicking the link below.
Find out more
Information about delivering quality care and quality improvement, alongside the Royal College of Emergency Medicine's Clinical Audit resources and reports.
Find out more
Health Informatics is the internationally recognised and Department of Health term covering the use of resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine.
Find out more
