Patient safety alert on placement devices for nasogastric tube insertion

Source:  NHS England

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Date of publication:  December 2013

Publication type:  News item

In a nutshell:  NHS England has issued a patient safety alert on the use of placement devices for inserting nasogastric tubes. Available from the Central Alerting System (CAS), this alert will ensure all hospitals and community services that use nasogastric tubes continue to follow previous guidance issued by the National Patient Safety Agency even when placement devices are used. It has been issued in response to two recently reported patient safety incidents.

Length of Publication:  1 web page

Closing the gate before the horse bolts: a new approach to patient safety

Source:  The Health Foundation

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Date of publication:  May 2013

Publication type:  Blog post

In a nutshell:  A blog post by Elaine Maxwell that considers whether care is any safer today than it was in 2001 when the National Patient Safety Agency was established.

Length of Publication:  1 web page

NPSA publishes patient safety incident data update

Source: National electronic Library for Medicines

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Date of publication: 13 September 2012

Publication type: News item

In a nutshell: Data workbooks covering organisation patient safety incident reports data for incidents that occurred between 1 October 2011 and 31 March 2012 and were reported to the National Reporting and Learning System (NRLS) by 31 May 2012 have been issued by the National patient Safety Agency (NPSA). Workbooks covering data by region and data by organisation are available.

Length of publication: 1 web page

Call for clarity over replacement for patient safety organisation

Source:  Nurs Stand. 2011 Aug 24-30;25(51):11

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Date of publication: August 2011

Publication type:  News item

In a nutshell:  The government is being asked to clarify who will carry out the National Patient Safety Agency’s work after the body is axed. There is a proposal in the Health and Social Care Bill to abolish the agency next year. The NHS Commissioning Board would take responsibility for reporting and learning from patient safety incidents in England.

Length of publication:  1 web page

Some important notes:  This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library

Understanding the patient safety issues for people with learning disabilities

Source: National Reporting and Learning Service, National Patient Safety Agency

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Date of publication: November 2010

Publication type: Guidance

In a nutshell: This report looks at the work the NPSA has done, and is continuing to do to improve the patient safety issues surrounding people with learning disabilities.  It also identifies priority patient safety issues.

Length of publication: 22 pages

A model for developing high-reliability teams.

Source: Anaesthesia  Vol 65 Iss 11 p1106-1113

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Date of publication: November 2010

Publication type: Journal article

In a nutshell: This article looks at the instances where misuse of an anaesthetic has casued adverse effects.  It also looks at providing recommendations on how to improve this.  The incidences were taken from the National Reporting and Learning System in England and Wales between 2006 and 2008.

Length of publication: 7 pages

Some important information:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Acknowledgement: EMBASE

After the abolition of the National Patient Safety Agency

Source: British Medical Journal

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Date of publication: 3 November 2010

Publication type: Editorial

In a nutshell: Abolishing the NPSA may include the NHS Reporting and Learning system, the national database of reported patient safety incidents. The database highlights areas of concern and provides evidence around the number and severity of incidents on a national scale.

Length of publication: Webpage

Some important notes: Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Safety when giving insulin in hospital

Source:  Nursing Times  Vol 106  Iss 39 p12-13

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Date of publication:  October 2010

Publication type:  Journal article

In a nutshell:  This article outlines the Rapid Response Report published by the National Patient Safety Agency in June 2010, looking at the risks involved with administering insulin and how these can be minimised.

Length of publication:  2 pages

Some important notes:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Acknowledgement:  CINAHL

Signals: emerging issues from national review of serious patient safety incidents

Source:  National Reporting and Learning Service, NPSA

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Date of publication:  October 2010

Publicaton type:  Report

In a nutshell:  Key risks have been identified from a review by the Patient Safety division of the NPSA into serious incidents which have been reported to the NHS.  These issues are in the form of Signals.  10 new ones have been published including ‘Wrong site nerve block’; ‘Non-invasive ventilation’ and ‘Overdose of intravenous paracetamol in infants and children’.

Length of publication:  Webpage

Acknowledgements:  National Patient Safety Agency

Patient Safety matters : reducing the risks of nasogastric tubes

Source:  Clinical Medicine: Journal of the Royal College of Physicians.  10(3)  pp. 228-230

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Date of publication:  June 2010

Publication type:  Journal article

In a nutshell:  The procedure of inserting nasogastric tubes by nurses and doctors is common within NHS hospital.  There have been a number of reports issued over the past 30 years into the results of wrong insertion, even death.  This article looks at the safety alert issued by the National Patient Safety Agency in England and how effective this has been to prevent errors from wrong insertion.

Length of publication:  3 pages

Some important notes:  Please  contact your local NHS library for the full text of the article.  Follow this link to find your local NHS library

Acknowledgements:  EMBASE.