Health Management and Policy Alert

Failures in communication or follow-up of unexpected significant radiological findings

Healthcare Safety Investigation Branch -
This report demonstrates where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiological findings. The investigation also makes three other recommendations in relation to following up unexpected significant radiological findings, to The Royal College of Radiologists, NHS England and NHS Improvement, and the Care Quality Commission.

• Report
• Healthcare Safety Investigation Branch - publications

The NHS patient safety strategy: safer culture, safer systems, safer patients

NHS - 

Patient safety is about maximising the things that go right and minimising the things that go wrong. It is integral to the NHS’ definition of quality in healthcare, alongside effectiveness and patient experience. This strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety. 

• Strategy
• More detail

Pounds for patients? How private hospitals use financial incentives to win the business of medical consultants

Centre for Health and the Public Interest - 

This report looks into how the private hospital sector uses financial incentives to attract NHS consultants to work for them. It argues that this could result in a potential conflict between consultants' income and patients’ best interests. The report was compiled between May 2018 and May 2019 using publicly available data on the websites of private hospitals, NHS trusts and Companies House.

• Report
• More detail

Medicines in health and adult social care: learning from risks and sharing good practice for better outcomes

Care Quality Commission - 

This report report describes lessons for better medicines optimisation across health and social care providers and the positive impact of involving pharmacy professionals in health and social care settings.

• Report
• Press rlease

Independent review of gross negligence manslaughter and culpable homicide

General Medical Council -
This independent review was commissioned following the death of Jack Adcock and the prosecution and conviction of Dr Hadiza Bawa-Garba for gross negligence manslaughter. This report is about how to achieve the aim of a just and fair culture in medicine and the need to learn, not blame, when things go wrong, for the benefit of both patients and the doctors who care for them.

• Report
• General Medical Council - news

Patient safety essentials toolkit

Institute for Healthcare Improvement - 

This toolkit includes documents on improving teamwork and communication, tools to help you understand the underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems. Each of the nine tools includes a short description, instructions, an example, and a blank template. Please note that free registration is required to access the toolkit.

• Toolkit

Learning Disability Mortality Review (LeDeR) programme: action from learning

NHS England - 
This report provides examples of the local changes that have been made to services so far and highlights the extensive work which is happening nationally in response to common themes raised through LeDeR reviews across the country.

• Report

Segregation in mental health wards for children and young people and in wards for people with a learning disability or autism

Care Quality Commission (CQC) -
This is the interim report of a review commissioned by the Secretary of State for Health and Social Care on the use of restraint, prolonged seclusion and segregation for people with a mental health problem, a learning disability or autism. It calls for an independent review of every person who is being held in segregation in mental health wards for children and young people and wards for people with a learning disability or autism. These reviews should examine the quality of care, the safeguards to protect the person and the plans for discharge.

• Report
• Press release

Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet

General Pharmaceutical Council -

This guidance explains what pharmacy owners should consider before deciding whether any parts of their pharmacy service can be provided safely and effectively at a distance (including on the internet), rather than in the traditional face-to-face way.

• Guidance
• Press release

Quality and safety of human blood and blood products if the UK leaves the EU without a deal

Department of Health and Social Care -

If the UK leaves the EU without a deal it will become a third country operating outside of EU rules. There will be some changes to the way blood and blood components are imported and exported. This guidance sets out what is required to ensure the safety and quality of blood and blood products.

• Guidance