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Safety Resource Centre

Safety Resource Centre

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.

Safety Resources

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.

This page is managed by the Safer Care Committee, which is part of the Quality in Emergency Care Committee (QECC). Further information about these committees can be found on the RCEM Board and Committees Structure page.

The QECC has produced a series of strategy documents, explaining the role of RCEM, and these committees, in improving patient care. These are:

If you would like to comment on the content of these pages, or become involved in these committees please contact the chairs of the committees.

What is Patient Safety?

Patient Safety emphasises the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. Providing safer care involves:

  • Identifying and managing patient-related risks
  • Reporting and analysing incidents
  • Addressing complaints and claims
  • Learning from and following-up on incidents
  • Implementing solutions to minimise the risk of incidents recurring.

Why is it important?

Patient safety is a serious public health issue. The World Health Organisation estimates that in developed countries as many as one in 10 patients is harmed while receiving hospital care.

Between July 2009 and June 2010 in England and Wales, over 800,000 incidents that did or could have harmed patients in acute hospital settings were reported to the National Patient Safety Agency1.

1. NRLS Quarterly Data Workbook (NPSA, Feb 2011)

What is the Royal College of Emergency Medicine doing about patient safety?

The College has established a Safer Care Committee which is undertaking the following:

  • Developing and disseminating patient safety and risk management strategies for the speciality of Emergency Medicine
  • Advising and collaborating with NRLS, NICE, DH, CQC, the Royal Colleges and other national bodies who have an interest in risk management and patient safety in Emergency Departments
  • Developing and identifying resources for patient safety
  • Informing Fellows and Members of patient safety research, key publications and resources
  • Reviewing of significant incident reports in emergency medicine

To see the terms of reference and committee members e-mail

Safety Flashes & News Alerts

+ Healthcare Safety Investigation Branch Reports

Healthcare Safety Investigation Branch Reports

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.

+ National Patient Safety Alerts

National Patient Safety Alerts

This page has links to recent flashes on equipment faults, high risk procedures etc, as well as other safety organisations.

Please contact if you hear of additional topics that should be on this page.

See all RCEM issued safety newsflashes in the tab below.

Central Alerting System

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.

Patient Safety Alerts

Links to NHS England, MHRA and Public Health England patient safety alerts can be found below:







MHRA Drug Safety Bulletin

Medical Device Alerts

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:





+ RCEM Safety Flashes

RCEM Safety Flashes

Click on the links below for the latest information.

Clinical Learning Case

Click on the link below for the latest information.

Legal Learning Case

Click on the link below for the latest information.

Older Newsflashes

+ Labelling blood transfusion samples from unknown patients

Labelling blood transfusion samples from unknown patients
29 july 2015

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.

  • A unique identification number, ideally using non-sequential numbers
  • The gender of the patient
  • A second, independent sample (taken at different time) be sent

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.

+ Insertion of chest drains

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.

+ Button batteries as a cause of haematemesis in children

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).

+ Addisonian crisis

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

+ Head injury in anti-coagulated patients

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:

+ Summary of Reports to Prevent Future Deaths

Summary of Reports to Prevent Future Deaths (formerly Rule 43 Reports)

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:

  • Training of staff
  • Processes and practice related to admission, handover or referral
  • Processes and practice related to discharge to community
  • Clinical care
  • Measurement and interpretation of vital signs
  • Staffing levels
  • Access to radiology
  • Availability of medical records

More detail regarding individual circumstances can be obtained here.

+ Surgical Never Events

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. This can be found here.

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.

+ Neonatal Equipment

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:

+ Sign up to safety

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

There are five pledges for safety:

  1. Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally.
  2. Continually learn. Make your department more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are.
  3. Honesty. Be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong.
  4. Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use.
  5. Support. Help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress.

Sign up and give your ideas to your Trust – make a difference today!

Please share any ideas with the College at

Should you have any feedback on these Safety Newsflash alerts please email

Guidance & Resources

+ Clinical Governance & Patient Safety Groups

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

Never Events

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.

  • Download this document here

If you have implemented any other mitigation not included in this guide please do let us know by emailing:

For further information about Never Events please visit the Department of Health and NHS England websites:

+ Organisations


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:

  1. National Reporting and Learning Service (NRLS) – collects and analyses errors across England and Wales
  2. National Clinical Assessment Service (NCAS)
  3. National Research Ethics Service (NRES)

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

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.

+ Safety Lead Resources + Second Victims

Second Victims

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:

+ Training Materials

Training materials

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.

Essential Reading

Francis Report

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.

Francis report: a call to arms

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.

You can view this document here.

Francis Report Recommendations – a Checklist for Senior Teams in Emergency Departments

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. Download this document here.

Francis Report – Statement for Fellows and Members

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. This document can be found here.

Berwick 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 here.

Non-technical Skills

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. Download this document here.

Integrating Safety Checklist

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.

Download the checklist as a pdf here.

Radiology Processes

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, which can be downloaded here.

Tools Resources and Systems

The Safer Care Team recommend that Emergency Medicine doctors utilise the below tools, resources and systems when considering patient safety.

Crisis Resource Management (CRM)

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.

Clinical Negligence Scheme for Trusts (CNST)

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.

Essentials of Patient Safety

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 more here.

Failure Mode and Effects Analysis (FMEA) – a methodology for analysing potential reliability problems. See:

FMEA: A model for reducing medical errors

M Chiozza, C Ponzetti

Clinica Chimica Acta

Volume 404, Issue 1, 6 June 2009, Pages 75-78

Global Trigger Tool (GTT)

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

NHS Evidence

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).

National Service Frameworks (NSF)

The National Service Frameworks cover some of the high priority conditions and key patient groups. They work to:

  • set clear quality requirements for care based on the best available evidence of what treatments and services work most effectively for patients, and
  • offer strategies and support to help organisations achieve these

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

Patient Safety First is a national campaign that aims:

  • to ensure the safety of patients is everyone’s highest priority
  • to reduce harm by changing in specific areas.

It is sponsored by the NHS Institute for Innovation and Improvement, the NPSA and the Health Foundation.

Plan, Do, Study, Act (PDSA)

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).

Patient Safety Alert (PSA)

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

Reporting incidents

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.

Staff Care, How to engage staff in NHS and why it matters

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.

Royal College of Emergency Medicine – Top tips for patient safety

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.

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