On Tuesday 17 September we recognised World Patient Safety Day. Each year, a new theme is selected to highlight a priority patient safety area needing urgent and concerted action, with this year’s theme focusing on “improving diagnosis for patient safety”.
The awareness day was originated by the World Health Organisation (WHO) and has been growing momentum on social media, offering a great opportunity to share some of our learning. Now in its fifth year, WPSD aims to raise public awareness to foster collaboration between patients, health workers, policymakers and healthcare leaders to improve patient safety.
This year we re-shared our three reports focusing on Emergency Department claims as well as Early Notification illustrative case stories.
You can see our LinkedIn posts below, along with two supporting quotes from NHSR colleagues:
Our Safety and Learning team has an active role in improving patient safety and publishes resources to help the system learn from incidents to reduce harm.
The World Patient Safety Day theme “Improving diagnosis for patient safety” resonates with one of the main findings across our Emergency medicine reports looking at high-value and fatality-related claims, missed fractures and hospital-acquired pressure ulcers and falls – that Emergency Department clinical services should provide timely identification of diagnoses and treatment plans for patients. This should include what to look out for and actions that should be taken if the patient deteriorates.
Good record-keeping and communication to support handover and ‘safety netting’ for patients – where they are followed up in a timely and appropriate manner – underpins the delivery of timely diagnoses and the delivery of effective treatment plans.
Michelle Stafford, Safety and Learning Lead (Midlands and East)
The Early Notification (EN) scheme illustrative case stories are developed by midwives, obstetricians and neonatologists working on the EN clinical team.
The case stories are developed for maternity/perinatal teams to support learning to improve patient safety. We have had some positive feedback from maternity units who are using the case stories to support professional development and use them as part of local training. The placental abruption case story focuses on the importance of robust regular risk assessments to support timely intervention and escalation.
The placental abruption case story focuses on concealed abruption, a challenging but life-threatening diagnosis with limited overt clinical signs or symptoms. The importance of holistic care, including excellent communication with the mother, robust regular risk assessments, timely categorisation of fetal monitoring and maintaining a high clinical vigilance is highlighted to support diagnosis, escalation and timely intervention.
It is also important to learn from examples of good practice; The Good Practice: Care outside of Guidance after previous Caesarean Section case story highlights how comprehensive, ongoing risk assessments and listening to the woman throughout pregnancy and intrapartum care can result in a timely diagnosis and a positive outcome for both mother and baby.
Annette Anderson, Head of Early Notification Team (Clinical)
