PATIENT SAFETY KEY DOCUMENTS

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Patient safety key documents
DH-published documents about patient safety.
Coding for Success: Simple technology for safer patient care
Published: 16 February 2007

New guidance to promote and support use of auto identification (barcoding and similar technologies) to increase patient safety and improve efficiency has been launched. There is evidence of real improvements to patient safety when coding systems are used to match patients to their care – reduced medication errors, reduced risk of wrong site surgery, accurate track and trace of surgical instruments, equipment and other devices and much better record keeping. Using coding to manage supplies and purchasing electronically can cut costs dramatically as well as improve efficiency.

This document has been written in partnership with DH, NPSA, MHRA, CfH and PASA. It recommends both industry and NHS adopt the GS1 system of coding standards and sets out an action plan that supports both NHS and industry.


Coding for Success: Simple technology for safer patient careSafety first: a report for patients, clinicians and healthcare managers
Published: 15 December 2006

This report was commissioned by Sir Liam Donaldson, Chief Medical Officer, to reconsider the organisation arrangements currently in place to ensure that patient safety is at the heart of the healthcare agenda. The report makes a number of key recommendations to build on the progress already achieved in embedding patient safety in the NHS.

Safety first: a report for patients, clinicians and healthcare managersRisk assessment of spinal procedures
The Chief Medical Officer's report An Organisation with a Memory set a goal for reducing to zero the number of patients dying or being paralysed by maladministered spinal injections. Among other measures toward this target, the Department of Health has been working to identify a safe spinal connector solution. The National Patient Safety Agency recently produced a risk assessment of spinal procedures with current safeguards and with three proposed new connector design options. An executive briefing explores Department of Health work to date.

Download Executive Summary (PDF, 33K)Design for patient safety
Published: 01/02/2004

The Design for Patient Safety report was jointly funded by the Design Council, a body that advises businesses and organisations on design, and the Department of Health. It follows an initial study undertaken by teams at The Robens Centre for Health Ergonomics, The Helen Hamlyn Research Centre and the Cambridge Engineering Design Centre.

Design for patient safetyHSC 2003/010 - Updated national guidance on the safe administration of intrathecal chemotherapy
This circular sets out the minimum requirements of an NHS Trust providing an intrathecal chemotherapy service. It also sets out what to do in the exceptional circumstance where an intrathecal chemotherapy procedure needs to take place in a Trust that should not normally provide this service. This guidance replaces circular, HSC 2001/022.

HSC 2003/010 - Updated national guidance on the safe administration of intrathecal chemotherapyAnnual report of the Chief Medical Officer 2002
This annual report highlights selected health issues from 2002 and the actions taken to overcome health problems.

Annual report of the Chief Medical Officer 2002Delivering the NHS Plan: next steps on investment, next steps on reform
Published: 18/04/2002

In this document the Secretary of State for Health presented a progress report on the NHS Plan. He detailed what had been achieved to date and the programme of changes yet to come. This document presented a progress report on the NHS plan up to 2002. Achievements to this point and planned changes to the programme were detailed.

Delivering the NHS Plan: next steps on investment, next steps on reformBuilding a safer NHS for patients - implementing an organisation with a memory
Published: 17/04/2001

'Building a safer NHS for patients' sets out the Government's plans for promoting patient safety.

Building a safer NHS for patients - implementing an organisation with a memoryExternal Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001
Published: 19/04/2001

The report details the work of the enquiry into the circumstances surrounding the death of this patient, who received, by intrathecal (spinal) administration, the correct treatment followed by Vincristine which 'should never be administered by the intrathecal route because it is nearly always fatal'.

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001The prevention of intrathecal medication errors: a report to the Chief Medical Officer
Published: 19/04/2001

Administration of Vinca alkaloids such as vincristine by the spinal route, rather than intravenously, invariably causes death or neurological damage. This catastrophic clinical error has arisen because of confusion of the drug with a cytotoxic agent intended to be given intrathecally (usually methotrexate). Five such incidents have occured in NHS hospitals in the past decade, representing an estimated rate of about three per 100,000 intrathecal chemotherapy treatments. This report adopts a systems approach to identify factors which have contributed to these errors and explores safety measures to reduce risk. Recommendations are made for an immediate action plan, implemented by national guidance and reinforced by clinical governance. Key elements are: formal designation within each Trust of medical staff competent to give intrathecal chemotherapy; steps to ensure that intrathecal and intravenous cytotoxic drug treatments are given at different times, by different people and in different clinical locations. Cites 10 references [Book abstract]

The prevention of intrathecal medication errors: a report to the Chief Medical OfficerAn organisation with a memory
Published: 13/06/2000

Adverse health care events cannot be eliminated from complex modern health care but the recommendations of this expert group are designed to ensure that lessons from the past are used to reduce the risk to patients in the future. The cost of adverse events is increasing; there is also a distressing similarity present in some of them. With clinical governance comes an opportunity to focus upon this problem. The extent of the serious failures in healthcare is outlined but the reporting and information systems of the NHS give an incomplete picture. Very little research on reporting and information systems has been done in UK. Specific types of adverse events are seen to repeat themselves at intervals, thus demonstrating that lessons have not been learned. To make progress four key areas need to be addressed throughout the service; these are detailed in ten recommendations. Cites 69 references in chapter order.

An organisation with a memory