This page is reserved for national reports and publications that may be of interest to members and readers of the website.
Where it is pink, it is a link
National patient safety incident reports. (March 2018)
Every six months NHSI publish official statistics on patient safety incidents reported to the NRLS. The NaPSIRs set out the number of patient safety incidents reported to the NRLS and describe their patterns and trends. The data include all patient safety incidents reported by NHS organisations in England.
Every month official statistics are published of the incidents reported to the NRLS which are collated by NHS Improvement. The information in these reports should be used alongside other local patient safety intelligence and expertise, and supports the NHS to deliver improvements in patient safety.
MHRA delivers guidance on Human Factors.; September 2017
In collaboration with key stakeholders, NHRA has produced guidance on the human factors aspects of design for medcial devices including those in drug-device combination products
Lord Carter of Coles Report – Operational productivity and performance in English NHS acute hospitals: Unwarranted variations – Feb 16
This review looked at productivity and efficiency in English non-specialist acute hospitals, which account for half of the total health budget, using a series of metrics and benchmarks to enable
comparison. We conclude that there is significant unwarranted variation across all of the main
resource areas, and although we found many examples of good practice, no one hospital is
good at everything.
NHS Five Year Forward View Oct 14
Fortunately there is now quite broad consensus on what a better future should be. This ‘Forward View’ sets out a clear direction for the NHS – showing why change is needed and what it will look like.Some of what is needed can be brought about by the NHS itself. Otheractions require new partnerships with local communities, localauthorities and employers. Some critical decisions – for example oninvestment, on various public health measures, and on local servicechanges – will need explicit support from the next government.
Professor Don Berwick, an international expert in patient safety, was asked by the Prime Minister to carry out the review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.
On February 6 2013, the Prime Minister announced that he had asked Professor Sir Bruce Keogh, NHS Medical Director for England, to review the quality of care and treatment provided by those NHS trusts and NHS foundation trusts that were persistent outliers on mortality indicators. A total of 14 hospital trusts were investigated as part of this review.
This independent review by Camilla Cavendish makes a number of recommendations on how the training and support of both healthcare assistants who work in hospitals, and social care support workers who are employed in care homes and people’s own homes, can be improved to ensure they provide care to the highest standard.
The review proposes that all healthcare assistants and social care support workers should undergo the same basic training, based on the best practice that already exists in the system, and must get a standard ‘certificate of fundamental care’ before they can care for people unsupervised.
New regulations setting out fundamental standards of quality and safety now enable the CQC to move to the next stage of development. The regulations are called the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They are more focused than the previous ones. They will enable the CQC to pinpoint more clearly the standards below which care must not fall, and take appropriate enforcement action, in line with Sir Robert Francis’s recommendations arising from his inquiry into care at Mid-Staffordshire NHS Foundation Trust.
The regulations also introduce a new duty of candour, and a fit and proper person requirement for directors, which will enable greater accountability of directors. These are significant changes.
NAMDET contributed to the new MHRA document (MHRA 2014) and added a number of key references to the importance of medical device training. The purpose of this document is to outline a systematic approach to the acquisition, deployment, maintenance (preventive maintenance and performance assurance), repair and disposal of medical devices and medical device training.
Key contributions from NAMDET members included reviewing safety systems, errors and incident reports. Medical device trainers may find the checklists and categories for IV therapy of use when developing training programes.
The final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry was published on Wednesday 6 February 2013. This report includes reference to ongoing leadership, knowledge, skills and competency to perform your role.
The Department of Health (DH) and Health Education England (HEE) share a vision of planning for future workforce needs and securing funding for education and training that is underpinned by accurate, comprehensive, complete and timely workforce information, to ensure the workforce truly reflects the needs of local service users. This will meet the needs of patients, and providers, and commissioners of healthcare.
DERS Dose Error Reduction Software.
NAMDET members have been involved in helping research into DERS systems in the UK and the following links may help you in your research and training programmes.
- Infusion Device Standardisation and the Use of DERS: a UK Survey (Iacovides et al, BJN July 2014)
- British Journal of Nursing booklet into DERS systems (July 2013)
- Supporting the implementation of smart pumps with DERS (David Upton Sept 2012)
The MHRA have produced the Top Ten Tips on Blood Pressure Measurement Devices. Serial 1 states the following:
The measurement of blood pressure is important in the diagnosis and monitoring of a wide range of clinical conditions. In this document the MHRA review the advantages and disadvantages of mercury, aneroid, electronic manual sphygmomanometers and automated blood pressure measuring devices. This should help to ensure the most appropriate technology is selected for use.
Ensure that only clinically validated equipment is purchased for use and that all sphygmomanometers are regularly checked — mercury devices at least annually andd aneroid devices at least twice a year. Automated devices should only be used if re-calibration is taken in accordance with the manufacturer’s instructions. It is good practice to delegate the task of ensuring regular calibration checks and maintenance to a designated individual.
A Framework for Technology & Learning – Simulation and simulated tasks have been used in medical, nursing and dental education for at least the last 50 years and e-learning has played a significant role for the last decade. As we embrace new technologies and refine existing approaches, it is essential that we review appropriate provision and use to ensure that we equip the workforce with the necessary capabilities for safe and effective patient care. This Framework, which has drawn upon expertise from the health and social care sectors, does just that.
Medical Gases information (HTM02-01) is the Department of Health (NHS Estates) Guidance document that outlines responsibilities, training requirements for both engineers, porters and nurses and contains useful information on course content, learning outcomes and health and safety considerations. This can be used to help develop your policy, training and competencies for internal training courses.