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Keeping up to Date with Global Patient Safety

One of the great difficulties in patient safety and health quality is keeping up to date with all the material that is produced. A myriad number of patient safety and health resources exist globally. By sharing good quality resources, we can help advance the global patient safety agenda.

NHS Resolution (the operating name of the National Health Service Litigation Authority) has excellent patient safety and clinical negligence resources, learning materials and should be viewed as a priority global information source.

NHS Resolution is a Special Health Authority and is a not-for-profit arm’s length body of the Department of Health and Social Care.It is a part of the NHS and has several functions including handling negligence claims on behalf of NHS organizations and independent sector providers of NHS care in England who are members of the NHS Resolution indemnity schemes.

Safety and learning function

NHS Resolution also has a function of advancing safety and learning in the NHS. The NHS Resolution web site states:

“We support members locally to better understand their claims risk profiles to target their safety activity and collaborate with others to sharing learning across the system at a national level.”

NHS Resolution have produced several safety and learning reports and some are noted below.

Needlestick Injuries: Safety and Learning Report

In terms of litigation trends,1,833 incident claims for needlestick injuries were received by NHS Resolution between 2012—2017 (fiscal years). Out of these there were 1,213 successful claims which NHS Resolution state cost the NHS £4,077,441 ($5,185,669)

This equates to funding for 125 band 5 nurses for one year. This harm and cost are largely avoidable NHS Resolution state:

“Most sharps injuries can be prevented, and there are legal requirements on employers to take steps to prevent healthcare staff being exposed to infectious agents from sharps injuries.” (P2).

The report states that 137 successful claims were made by clinical staff in the period. Cause themes identified in the report are:

  • non-compliance with standard infection control precautions;
  • inadequate disposal of clinical waste;
  • overfull sharps bins;
  • not using safer sharps; and
  • not using Personal Protective equipment. (p3)

Assaults: Safety and Learning Report

NHS staff are increasingly becoming victims of violent assaults.

£53.4 Million ($ 67.9 Million) will be spent settling 1,255 of the 3,227 claims made for assault received by NHS Resolution between 2013 and 2018.This equates, the report states, to employing 1,700 registered nurses for one year.

Common claim factors stated in the report include:

  • Incomplete evidence of staff de-escalation and safety training • Lack of timely medical reviews and documentation of rationale for medication choice • Poor post incident support to staff • Lack of a systemic and systematic communication approach. (p 4).

Things to consider include maintaining risk assessment records with family and carer information. Document rationale for treatment and medication, ensure regular staff training, ensure clear communication between care settings during investigations.

Saying sorry: leaflet

NHS Resolution have produced a leaflet on saying sorry which contains lots of helpful advice. Why say sorry?

“Saying sorry is: always the right thing to do, not an admission of liability, acknowledges that something could have gone better, the first step to learning from what happened and preventing it recurring” (p2)

The leaflet reminds the reader that saying sorry is not only a moral and right thing to do, it is also a statutory, regulatory and professional requirement. The leaflet states that the way you say sorry is just as important as saying it.

NHS Resolution materials should be regarded as one of the essential global learning resources on patient safety learning.

 

John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I am also a Patient Safety Specialist at ECRI Institute. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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