An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales

Lankshear, Annette Jean; Lowson, Karin; Weingart, Saul N.

doi:10.1136/bmjqs.2010.040287

Cited by 13 publications

(9 citation statements)

References 11 publications

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“…A multimethod independent research study, comprising focus groups and interviews with NHS Chief Pharmacists and an electronic survey of medical, nursing and clinical governance directors, has assessed the quality and impact of the NPSA medication safety outputs [27]. The research concluded that, ‘ within the NHS, there was a high degree of satisfaction with the medication safety topics addressed which were, with few exceptions, perceived to pose a high risk to patients.’…”

Section: Discussionmentioning

confidence: 99%

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

Cousins

Gerrett

Warner

2012

Brit J Clinical Pharma

157

138

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was undertaken. The 526 186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394 951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44 952) from primary care, representing 8.5% of the total. Of 86 821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263 228; 50%) and prescribing (97 097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82 028; 16%) and wrong dose (80 170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance.

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Section: Discussionmentioning

confidence: 99%

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

Cousins

Gerrett

Warner

2012

Brit J Clinical Pharma

157

138

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“…The fact that deaths have continued clearly shows that the implementation of mitigation measures set out in the alert was suboptimal, or that their effectiveness is suboptimal, or both. Patient safety incident reporting systems have been criticised for weaknesses in cascading their learning to frontline staff,26 and it is unclear what effect national patient safety alerts have on the delivery of safer care 27…”

Section: Discussionmentioning

confidence: 99%

What is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance study

et al. 2014

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ObjectiveTo estimate the risk of death or severe harm due to bone cement implantation syndrome (BCIS) among patients undergoing hip hemiarthroplasty for fractured neck of femur.SettingHospitals providing secondary and tertiary care throughout the National Health Service (NHS) in England and Wales.ParticipantsCases reported to the National Reporting and Learning System (NRLS) in which the reporter clearly describes severe acute patient deterioration associated with cement use in hip hemiarthroplasty for fractured neck of femur (assessed independently by two reviewers).Outcome measuresPrimary—number of reported deaths, cardiac arrests and periarrests per year. Secondary—timing of deterioration and outcome in relation to cement insertion.ResultsBetween 2005 and 2012, the NRLS received 62 reports that clearly describe death or severe harm associated with the use of cement in hip hemiarthroplasty for fractured neck of femur. There was one such incident for every 2900 hemiarthroplasties for fractured neck of femur during the period. Of the 62 reports, 41 patients died, 14 were resuscitated from cardiac arrest and 7 from periarrest. Most reports (55/62, 89%) describe acute deterioration occurring during or within a few minutes of cement insertion. The vast majority of deaths (33/41, 80%) occurred on the operating table.ConclusionsThese reports provide narrative evidence from England and Wales that cement use in hip hemiarthroplasty for fractured neck of femur is associated with instances of perioperative death or severe harm consistent with BCIS. In 2009, the National Patient Safety Agency publicised this issue and encouraged the use of mitigation measures. Three-quarters of the deaths in this study have occurred since that alert, suggesting incomplete implementation or effectiveness of those mitigation measures. There is a need for stronger evidence that weighs the risks and benefits of cement in hip hemiarthroplasty for fractured neck of femur.

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“…For this, one hypothesis we consider is that the benefits from alerts and guidelines are proportional to the degree of their implementation; there is particularly limited evidence on the latter. A search of the literature finds one publication, which describes good compliance with feedback report implementation [11], whereas two publications report mixed awareness and implementation effort across NHS organisational levels [12,13]. The equivocal evidence on implementation steers the choice of study design, as we now discuss.…”

Section: Defining and Measuring Economic Valuementioning

confidence: 88%

A national incident reporting and learning system in England and Wales, but at what cost?

Carter

Mossialos

Darzi

2015

Expert Review of Pharmacoeconomics & Outcomes Research

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An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales

Abstract: Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safety.

Cited by 13 publications

References 11 publications

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

What is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance study

A national incident reporting and learning system in England and Wales, but at what cost?

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