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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: further information about these committees can be found on the RCEM ‘Structure and Governance’ Committees pages available here.

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@rcem.ac.uk

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 Safety Flashes

National Safety Flashes

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.

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:

2021

2020

2019

2018

2017

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:

2021

2019

2018

2017

+ 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 www.signuptosafety.nhs.uk

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 safety@rcem.ac.uk

Should you have any feedback on these Safety Newsflash alerts please email safety@rcem.ac.uk

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: safety@rcem.ac.uk

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

+ Organisations

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 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.

+ Safety Lead Resources

Details to follow

+ 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:

  • Download ’Supporting the Second Victim’ here.
  • Download our summary of recommendations here.
+ 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.

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