Ignoring the alarms: how NHS eating disorder services are failing patients

Parliamentary and Health Service Ombudsman - This report of an investigation that found that Averil Hart's death from anorexia would have been avoided if the NHS had cared for her appropriately. It highlights five areas of focus to improve eating disorder services. Click here to read further.

Emergency department (ED) patient safety checklist

This checklist has been proven to improve clinical processes and reduce serious incidents from unrecognised patient deterioration in crowded emergency departments.

Managing safety incidents in NHS screening programmes

Guidance from Public Health England, describing the process for managing safety incidents in the NHS screening programmes.

Monthly data on patient safety incident reports

Rolling data updated monthly, to show the number of patient safety incidents reported to the National Reporting and Learning System (NRLS) in the last 12 months.

The data is based on the date each incident report was submitted to the NRLS and not the date the incident was said to have occurred. It represents the current position at the time data was extracted from the NRLS and is subject to change, should any reports be updated as further information becomes available.

The data is broken down by each month reported and degree of harm, and is refreshed and updated on a monthly basis.

• NRLS monthly incident report England: July 2016 to June 2017

Patient death reveals 'no coordination' between mental health services

A coroner has raised concerns about the lack of coordination in mental health services for young people in Birmingham, after a patient under NHS care was found hanged. Read more HERE (subscription to HSJ required)

Organisation patient safety incident reports

Data workbooks and explorer tool based on incidents reported by NHS providers in England to the National Reporting and Learning System (NRLS).

Development of the Patient Safety Incident Management System (DPSIMS)

The DPSIMS is the successor to NRLS and with business case being developed in preparation for delivery to the NHS over the next three years.

The NRLS is now almost 10 years old and due for an upgrade, and so the DPSIMS project aims to identify and assess the options for a successor system that will build upon the success of NRLS, but potentially expand its functions to create a Patient Safety Incident Management System (PSIMS) that will better meet the needs of patients and clinicians within current NHS delivery models, with the intention of delivering a new system in 2018.

Reminder to report all incidents of unsafe care

CQC’s recent Section 29 letter to Worcestershire Acute Hospitals Trust noted that staff had been told that their incident reports, on patients being cared for in areas they considered unsafe, were inappropriate and would be deleted.

A patient safety incident is “any unintended or unexpected event that could have or did harm a patientopens in a new window”. This clearly encompasses situations where staff are concerned they cannot provide safe care. Staff should never be discouraged from making such reports and, even if in other circumstances an incident report is genuinely inappropriate, incident reports should never be deleted.

Reducing sepsis and saving lives

NHS Improvement spoke to Joan Pons Laplana, Transformation Nurse at James Paget University Hospitals NHS Foundation Trust, to find out how he has helped to reduce the incidents of death caused by sepsis at the trust by putting some simple and low-cost new measures in place.

The Health Foundation has selected eight projects for its new Evidence into Practice programme

The Evidence into Practice programme will enable the selected research teams to use their innovative and creative ideas and translate their findings from completed studies in improvement research, or more broadly in health services research, into actionable practical tools for practitioners in health services or health policy.

Each research team will receive £50,000 for the development of tools and resources to support the implementation of findings into practice. Each project will be funded for 15 months.

The eight projects are:

1. A short animated film and other visual resources to support recognition and response to eating disorders in the perinatal period
Organisation: King’s College London, Institute of Psychiatry, Psychology and Neuroscience

2. A hand-drawn animation exploring accelerating systems thinking in health care incident investigation
Loughborough University

3. On-line tools for GPs to help support new migrants in primary care
University of Sheffield

4. Online resource pack with infographics, videos and downloadable materials on REasonable adjustments to MAINstream diabetes and obesity care for adults with a learning disability (REMAIN)
Leeds Institute of Health Sciences, University of Leeds

5. Online platform dedicated to innovation in breathlessness management (E-Breathe)
King’s College London. Cicely Saunders Institute,

​6. A year in an hour: Quality Improvement through Interactive Simulations (QIIS)
Chelsea and Westminster Hospital

​7. Short videos outlining key messages for better tracheostomy care
University Hospital South Manchester

​8. In Control: a 40 minute theatre piece and workshop to challenge, empower and provoke conversations amongst adolescents with asthma and their peers
Barts and The London School of Medicine and Dentistry, Queen Mary, University of London

Care Quality Commission reviews how NHS acute trusts are learning from serious incidents

CQC has published the findings of its review of how acute NHS trusts report on investigations into serious incidents, and the extent to which they identify learning that can be used to improve practice when things go wrong.

The review – Learning from serious incidents in NHS acute hospitals: A review of the quality of investigation reports – was based on a sample of 74 investigation reports from 24 NHS acute hospital trusts.

The findings of the review have been published in a briefing paper which highlights a variation in the quality of investigations, and also provides a number of good practice examples and identifies the following five opportunities for improvement for NHS acute trusts:

1. Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident.
2. Routinely involving patients and families in investigations.
3. Engaging and supporting the staff involved in the incident and investigation process.
4. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
5. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.