National Patient Safety Agency

London, United Kingdom

National Patient Safety Agency

London, United Kingdom
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Young people (aged 0-18 years) have been disproportionately affected by pandemic influenza A H1N1 infection. We aimed to analyse paediatric mortality to inform clinical and public health policies for future influenza seasons and pandemics. All paediatric deaths related to pandemic influenza A H1N1 infection from June 26, 2009, to March 22, 2010 in England were identified through daily reporting systems and cross-checking of records and were validated by confirmation of influenza infection by laboratory results or death certificates. Clinicians responsible for each individual child provided detailed information about past medical history, presentation, and clinical course of the acute illness. Case estimates of influenza A H1N1 were obtained from the Health Protection Agency. The primary outcome measures were population mortality rates and case-fatality rates. 70 paediatric deaths related to pandemic influenza A H1N1 were reported. Childhood mortality rate was 6 per million population. The rate was highest for children aged less than 1 year. Mortality rates were higher for Bangladeshi children (47 deaths per million population [95 CI 17-103]) and Pakistani children (36 deaths per million population [18-64]) than for white British children (4 deaths per million [3-6]). 15 (21) children who died were previously healthy; 45 (64) had severe pre-existing disorders. The highest age-standardised mortality rate for a pre-existing disorder was for chronic neurological disease (1536 per million population). 19 (27) deaths occurred before inpatient admission. Children in this subgroup were significantly more likely to have been healthy or had only mild pre-existing disorders than those who died after admission (p=0·0109). Overall, 45 (64) children had received oseltamivir: seven within 48 h of symptom onset. Vaccination priority should be for children at increased risk of severe illness or death from influenza. This group might include those with specified pre-existing disorders and those in some ethnic minority groups. Early pre-hospital supportive and therapeutic care is also important. Department of Health, UK © 2010 Elsevier Ltd.

Agency: European Commission | Branch: FP7 | Program: CSA-CA | Phase: HEALTH-2007-3.1-3 | Award Amount: 2.24M | Year: 2009

Medicines are one of the most common health interventions. Expenditure on pharmaceuticals range from 1020 % of all health expenditure in rich countries & from 2060 % in poor countries. Knowledge of appropriate & safe medicines has grown. But the incidence of medicines adverse effects remains high. In a UK study 6.5% of hospitals admissions were related to an adverse drug reaction (ADR). And as many as 10% of hospital admissions may result in death or disease due to errors, half of which may be avoidable. There are gaps in what we know. But even where there is sufficient knowledge, brokering of that knowledge is insufficient. There is a clear & present need to build a network of stakeholders in patient safety, to strengthen information & share the evidence towards actionable learning. The EC Work Programme for 20072008 relating to health calls for projects that advance the applications of evidence based medicine in Europe. This proposal will respond to that call by strengthening what we know about medicines, sharing that knowledge, & putting that knowledge to use, to reduce patient deaths & adverse effects due to medicines. Specifically, building patient safety networking to: 1. support & strengthen consumer reporting of ADRs & adverse events 2. expand the role of national pharmacovigilance centres to prevent medicine-related adverse events 3. promote better & broader use of existing pharmacovigilance data for patient safety 4. develop additional methods of pharmacovigilance to complement data from spontaneous reporting systems. Achieving these objectives will help build the scientific basis needed for making informed policy decisions on disease prevention & therapy, & management of resources for health. In particular achieving these objectives will help to identify best clinical practice, to understand decision-making in clinical settings in primary & specialized care & to foster application of evidence-based medicine & patient empowerment.

Healey F.,National Patient Safety Agency | Treml J.,University of Birmingham
Age and Ageing | Year: 2013

Background: in 2007, the National Patient Safety Agency (NPSA) published 'Slips trips and falls in hospital' and 'Using bedrails safely and effectively'.Objectives: this observational study aimed to identify changes in local policies in hospitals in England and Wales following these publications.Method: policies in place during 2006 and 2009 were requested from 50 randomly selected acute hospital trusts and their content was categorised by a single reviewer using defined criteria.Results: thirty-seven trusts responded. Trusts with an inpatient falls prevention policy increased from 65 to 100%, the use of unreferenced numerical falls risk assessments reduced from 50 to 19%, and trusts with a bedrail policy increased from 49 to 89%. It was concerning to find that by 2009 advice on clinical checks after a fall was available in only 51% of trusts, and only 46% of trust policies included specific guidance on avoiding bedrail entrapment gaps.Conclusions: the observed changes in policy content were likely to have been influenced not only by the NPSA publications but also by contemporaneous publications from the Royal College of Physicians' National Audit of Falls and Bone Health, and the Medicines and Healthcare products Regulatory Agency. Most areas of local policy indicated substantial improvement, but further improvements are required. © The Author 2012. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved.

Allegranzi B.,First Global Patient Safety Challenge | Nejad S.B.,First Global Patient Safety Challenge | Combescure C.,University of Geneva | Graafmans W.,First Global Patient Safety Challenge | And 5 more authors.
The Lancet | Year: 2011

Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries. We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence - including overall health-care-associated infection and major infection sites, and their microbiological cause - were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis. Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95 CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95 CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance. The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices. World Health Organization. © 2011 Elsevier Ltd.

Bion J.F.,University of Birmingham | Abrusci T.,University of Birmingham | Hibbert P.,National Patient Safety Agency
British Journal of Anaesthesia | Year: 2010

Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care. © The Author [2010].

Norris B.,National Patient Safety Agency
Nursing standard (Royal College of Nursing (Great Britain) : 1987) | Year: 2012

The aim of this series is to introduce the topic of human factors and to show how it can be used in nursing practice on the ward and in nursing management, to improve the safety of patient care. Human factors can be used to make many aspects of working life easier, and if it is easier to do it is less likely to go wrong. This article discusses the importance of human factors in nursing and provides some practical suggestions on how to apply the principles of human factors. Forthcoming articles will examine human factors tools, surgical safety and human reliability in more detail.

Cousins D.H.,National Patient Safety Agency | Gerrett D.,National Patient Safety Agency | Warner B.,National Patient Safety Agency
British Journal of Clinical Pharmacology | Year: 2012

A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1 January 2005 and 31 December 2010 was undertaken. The 526186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44952) from primary care, representing 8.5% of the total. Of 86821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263228; 50%) and prescribing (97097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82028; 16%) and wrong dose (80170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance. © 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.

Cousins D.,National Patient Safety Agency
Clinical medicine (London, England) | Year: 2011

Patient safety incidents involving insulin are frequent and cause considerable distress to people with diabetes and anxieties to their families and carers. This article describes an analysis of the National Reporting and Learning System database of patient safety incidents concerning insulin reported from NHS providers in England and Wales over six years. The main causes are discussed and the ongoing developments by the National Patient Safety Agency and partner organisations to reduce insulin errors are described.

Rocos B.,National Patient Safety Agency | Donaldson L.J.,National Patient Safety Agency
Annals of the Royal College of Surgeons of England | Year: 2012

Introduction: Surgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS) database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires. Methods: The NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011. Each report was scrutinised manually to discover the cause of the fire. Results: Thirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spiritbased surgical skin preparation or preparation soaked swabs and drapes. Conclusions: Despite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring.

Archer J.C.,University of Plymouth | Mcavoy P.,National Patient Safety Agency
Medical Education | Year: 2011

CONTEXT Multi-source feedback (MSF) and patient feedback (PF) are used increasingly around the world to assess and quality-assure clinical practice. However, concerns about the evidence for their utility pertain to their ability to identify poor performance, the impact of allowing assessees to select their own assessors and the many confounders that may undermine validity. METHODS This study was conducted in conjunction with the National Clinical Assessment Service (NCAS) in the UK and used established MSF and PF instruments to assess doctors in potential difficulty. Multi-source feedback assessors were nominated by both the practitioner (Pnom) and the referring body (RBnom). Demographics were collected to elucidate any differences found. Ratings generated by MSF and PF were compared with one another and with findings of a previous study that provided a normative cohort. RESULTS Using MSF, NCAS-assessed doctors scored significantly lower than the reference cohort. Nineteen (28%) NCAS-assessed doctors achieved scores that were less than satisfactory. This rose to 50% when only RBnom assessors were used. Overall, ratings awarded by RBnom assessors were significantly lower than those awarded by Pnom assessors. Collected demographics did not help to explain the difference. Only one NCAS-assessed doctor scored below average according to PF. Doctors in the NCAS-assessed group did not score significantly lower than the reference cohort in PF. Doctor assessment scores awarded by patients were significantly higher than those awarded by colleagues. CONCLUSIONS Although colleagues appear to report poor performance using MSF, patients fail to report concurrent findings. This challenges the validity of PF as it is currently constructed. Scores in MSF differ significantly depending on whether they are practitioner- or third party-nominated. Previously recognised confounding factors do not help to explain this difference. © Blackwell Publishing Ltd 2011.

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