We posted a blog on the safety watchdog's report in May and now, this week, the Healthcare Safety Investigation Branch has published its update documenting NHS Improvement and the Royal College of Physicians’ responses to its recommendations aimed at driving improvement to reduce potentially fatal medication errors.
HSIB's investigation report emphasised that overly complex and fragmented medicine safety processes are putting patients at risk. The report followed an investigation that was launched after it was made aware that a nine-year old child was wrongly administered an oral liquid drug into a vein during a planned renal biopsy – a never event. The child suffered no adverse effects following this incident.
HSIB made four safety recommendations –NHSI respond to three of those and RCP respond to one
In broad terms, the recommendations have been embraced and action taken on a number of levels.
NHSI
Recommendation 1: NHSI through the National Patient Safety Alert Committee set standards for all issuers of patient safety alerts which make clear that issuers should assess for unintended consequences, the effectiveness of barriers and provide advice for implementation and ongoing monitoring.
Response: Aidan Fowler, National Director of Patient Safety, confirmed that the 2018 standards include a procedure for: an assessment of the actions for potential unintended consequences and of the likely effectiveness of the actions in reducing future harm. The standards also include a requirement for the alert-issuing body to set out what types of supporting materials should be provided – this is intended to support providers with implementation and ongoing monitoring where required. Fowler comments that a key aspect of NaPSAC’s work is the role of the CQC in inspecting compliance with National Patient Alerts. NaPSAC’s standards became active on 13 May 2019.
Recommendation 2: Support the development of necessary knowledge, skills and capacity for the effective operationalisation of hazard identification and risk analysis at a national, regional and local level.
Response: Aidan Fowler confirmed that they are working with Health Education England to develop the first universal patient safety syllabus and training programme for the whole of the NHS.
Recommendation 3: Undertake a formal evaluation of banding, time and resource given to the Medication Safety Officer role.
Response: Internal work has begun to the review the Medication Safety Officer and Medical Device Safety Officer networks and their effectiveness, in the context of the recently published patient safety strategy which includes the establishment of Patient Safety Specialists for all organisations.
Royal College of Physicians
Recommendation: To provide leadership in recommending post graduate learning needs and activities to standardise professional development in medicines safety processes.
Response: RCP has coordinated a joint working group with other professional bodies to jointly develop and deliver work related to medication safety. Over the next 12 months, there is a plan to review the evidence on mediation safety, explore best practice, develop new models of inter-professional training and look at ways of spreading best practice.
We are already seeing evidence of the ‘golden thread’ of the new patient safety strategy running through NHSI initiatives and RCP’s responses.
Jill Mason, Partner and Head of Health & Care
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