Alerts
News
Update to the Transfer of Care Concern Policy
The Transfer of Care process has been updated to include details of the incident manager for Community Services.
If you have a transfer of care concern that relates to a community service then it can be reported as detailed on the contact sheet and concern form.
EMIS LV Practices required for QResearch
As an EMIS LV practice, we would like to invite you to contribute to the QResearch database. Your contribution will help to improve patient care through good quality research on large volumes of data.
All you need to do to help us with QResearch is activate your system. Please email Julia.hippisley-cox@nottingham.ac.uk with your CDB number. EMIS will then undertake the activation so that there is no work involved for the practice.
Please read the invitation for full details on how your practice can contribute to the QResearch database.
National mandatory reporting requirements for GP practices
From 1 April 2012 it will be a mandatory obligation to report events when patients are involved in incidents and experience avoidable ‘harm’.
There is already an NPSA online system for doing this and the CQC will check to see if practices are reporting to the national database.
View the NPSA online system, choose the appropriate link, then at the end of the form please tick ‘yes’ to share with PCT.
Medical Device Alert - 20 January 2011
Please check this alert to ensure that all staff are aware of:
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How to report a medical device related adverse incident,
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When to report a medical device related adverse incident,
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Who to report to,
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How to report to the Healthcare Products Regulatory Agency Adverse Incident Centre.
Invitation for early registration for Practice Accreditation Programme
It is a real pleasure to invite you to register now for the Royal College of General Practitioners (RCGP) Practice Accreditation (PA) scheme. As a practice who has expressed an interest in the programme, I am sure you will be interested in our 'early bird' discount for practices who register before 1 April 2011.
The scheme is our response to the drive for quality improvement within primary care and will provide practice teams with a development model that will support them to achieve the highest quality of care for patients. It has also gained the support of a wide range of stakeholders including the General Practitioners Committee of the British Medical Association, General Medical Council, Royal College of Nursing, NHS Confederation of Primary Care Trusts, Care Quality Commission, Department of Health, and patient groups.
Download a quick start guide, which provides details of the scheme, the fees and an application form. Practices applying before 1 April 2011 can take advantage of a £200 discount on the standard registration fee. An additional £50 discount will be applied to practices participating in the RCGP Research Ready initiative. If you are part of a group of practices, the guide provides details on how to register and pay.
As soon as we have processed your registration, you will receive the Standards, and you will then be able to begin gathering the relevant supporting information as you work towards achieving accreditation. Additional resources, support and the facility to submit your supporting information for assessment will be available within the PA website, which will be launched in April 2011.
If you have any queries, please do not hesitate to contact the Practice Accreditation office using the main RCGP number below or via email at practiceaccreditation@rcgp.org.uk.
We look forward to receiving your registration soon.
Dr Robert Varnam
Clinical Lead (Practice Accreditation)
Quality Account Report
This report details the lessons learnt from the first quality accounts submitted by NHS providers.
Medical Device Alert - 4 January 2011
Please check this alert to ensure that all staff are aware of:
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How to report a medical device related adverse incident,
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When to report a medical device related adverse incident,
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Who to report to,
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How to report to the Healthcare Products Regulatory Agency Adverse Incident Centre.
Rapid response report
Issue
Ambulatory syringe drivers are widely used in palliative care and for long term care in the community and in hospital. As a result they are often used to deliver opioids and other palliative care medication. Over infusion of these medications can cause death through respiratory depression, while under-infusion can leave the patient in pain and distress.
While the majority of syringe drivers and pumps used in healthcare have rate settings in millilitres (ml), some older types of ambulatory syringe drivers have rate settings in millimetres (mm) of syringe plunger travel. This is not intuitive for many users and not easy to check. Errors include the wrong rate of infusion caused by inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device. Dose errors also occur because of different models using mm per hour or mm per 24 hours. Other issues include syringes becoming dislodged, inadequate device alarms and lack of internal memory (a technical issue which makes establishing the reason for any over or under infusion difficult).
Evidence of harm
Between 1 January 2005 and 30 June 2010 the NPSA received reports of eight deaths and 167 non-fatal reports involving ambulatory syringe drivers. Four of the deaths were reported in 2009. Many of these incidents described infusions that had either run through much quicker than expected or had not infused at all.
Reducing the risk
Older types of ambulatory syringe drivers with rate settings in millimetres of syringe plunger travel have already been removed from the market in Australia and New Zealand. Some cancer centres and palliative medicine centres in the UK have replaced all their mm-calibrated ambulatory syringe drivers with ml-calibrated devices which include additional safer design features. Therefore a co-ordinated approach and timescale for the changeover will help to minimise additional risks arising from the introduction of safer equipment.
Practice Nurse News
Following the successful conference in September at Ashford International Hotel, please download the documents below to access useful information. Also see posters to print out and display.
Posters
Serious Incident Investigations
The National Framework for Reporting and Learning from Serious Incidents was published by the National Patient Safety Agency in March 2010.
NPSA Rapid Response Report
Summary of the Problem:
A loading dose is an initial large dose of a medicine used to ensure a quick therapeutic response. It is usually given for a short period before therapy continues with a lower maintenance dose. The use of loading doses of medicines can be complex and error prone. Incorrect use of loading doses or subsequent maintenance regimens may lead to severe harm or death.
NHS organisations should have procedures in place to ensure:
All medicines used by the organisation that are likely to cause harm if loading doses and subsequent maintenance doses are not prescribed and administered correctly are risk assessed and used to produce a list of critical medicines (which may contain speciality subsections). This must include warfarin, amiodarone, digoxin, phenytoin and any other medicines identified locally.
There is effective communication regarding loading dose and subsequent maintenance dose regimens when prescribing, dispensing or administering critical medicines. This should include handover of patients between healthcare organisations. Tools such as loading dose work sheets, loading dose prescription charts, handover and clinical protocols, and patient-held information should be considered.
Clinical checks are performed by medical, nursing and pharmacy staff (when available) so that loading and maintenance doses are correct. Appropriate information should be available to support these checks.
Healthcare professionals in the community know when to challenge abnormal doses of the identified critical medicines.
Leading Improvement in Patient Safety in General Practice (LIPS)
Develop and refine your patient safety improvement plan with the help of this free training course. The course is delivered over 5 days and aims to give you the skills and confidence to achieve a sustained reduction in patient harm and drive forward improvements in your practice.
To register email safercare@institute.nhs.uk or debra.vidler@eastcoastkent.nhs.uk before 1 September.
For more information go to www.institute.nhs.uk/safercare/GP
Getting started with safety improvement event feedback
The Patient Safety team hosted a Getting Started with Patient Safety afternoon on the 30 June 2010.
The national GP clinicians Dr Robert Varnum and Dr Paresh Dawda from the NHS Institute for Innovation and Improvement facilitated the training and there were attendees from GP Practices and Care Home managers.
Presentations from the Risk and Safety in pharmacy event – 17 May 2010
Learning from incidents
The Patient Safety Team has released a special learning alert following an investigation into a serious untoward incident. The incident highlighted the importance of accurate medicines reconciliation between providers. Please use this link to access the learning recommendations following this incident.
19 May 2010
Needlestick injuries
Recently a Healthcare Assistant accidently pricked herself with a dirty needle. Unfortunately she didn’t report it until the next day and she wasn’t seen for another 2 days. With an increasing number of healthcare assistants being trained to take blood from patients, it is possible that they are not as well informed about the correct procedures following a needle stick injury as qualified nurses are so please make sure the correct protocols as outlined on the GP website are clear to all staff taking blood.
20 January 2010
January’s edition of the NHS Institute for Innovation and Improvement includes the following articles relevant to Primary Care:
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Workshops for Better Care, Better Value indicators
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Research and evaluation service
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Webinars for GPs and senior primary care nurses
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Latest 'How to why to guide'
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Additional forthcoming events.
Patient Safety newsletter
NPSA alerts
NPSA policy e-bulletin
