Health Management and Policy Alert

The role and functions of CCG medicines optimisation teams

Nuffield Trust - 

This report reflects on the crucial role and functions that clinical commissioning group medicines optimisation teams deliver in the existing healthcare architecture to improve patient care.

• Report
• More detail

Adult social care extension to Infection Control and Testing Fund ring-fenced grant 2021

Department of Health and Social Care -
This guidance sets out the measures that the extension to the Infection Control and Testing Fund supports, including distribution of funds, conditions and reporting requirements. The Department of Health and Social Care have extended the fund until 30 September 2021.

• Guidance
• Department of Health and Social Care - publications

Consultation on the appointment and operation of the Patient Safety Commissioner

Department of Health and Social Care -
This consultation seeks views and any comments from those who may be affected or have a particular interest in the set up and functions of the new Patient Safety Commissioner for England. It closes on 5 August 2021.

• Consultation
• Department of Health and Social Care - consultations

Wrong site surgery – wrong patient: invasive procedures in outpatient settings

Healthcare Safety Investigation Branch (HSIB) - 

This investigation drew on the field of human factors to understand how the outpatient context influences the reliability of patient identification. It sought to identify the risks associated with the identification of patients specifically attending for invasive procedures in outpatients, and potential opportunities to manage or minimise them. As a result, HSIB recommend that NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise.

• Report
• Press release

Outpatient appointments intended but not booked after inpatient stays

Healthcare Safety Investigation Branch -
This investigation explores the patient safety risk of outpatient appointments which are intended but not booked following an inpatient stay. It also considers opportunities for building resilience into the process to ensure timely appointments. It concludes with two safety recommendations that are aimed at reducing the chance that patients will be lost after an inpatient stay and supporting the staff within trusts who are responsible for arranging appointments and tracking patients.

• Report
• Healthcare Safety Investigation Branch - news

Maternity and neonatal safety champions toolkit

NHS England -
This toolkit aims to provides information and resources to support safety champions to develop strong partnerships, promote positive professional cultures, and support the delivery of the safest care possible through best practice.

• Toolkit
• NHS England - publications

Never events: analysis of HSIB's national investigations

Healthcare Safety Investigation Branch (HSIB) -
‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. This national learning report examines the findings of the investigations previously carried out by HSIB concerning incidents classified as 'never events'.

• Report
• Summary

MBRRACE-UK Perinatal Confidential Enquiry: stillbirths and neonatal deaths in twin pregnancies

MBRRACE-UK - 
This report represents the findings of the fourth perinatal confidential enquiry and focuses on stillbirths and neonatal deaths in twin pregnancies. This report contains illustrative vignettes which are taken from real life events. The vignettes are used to illustrate single aspects of care and are not intended to describe all the care provided to individual mothers and their babies.

• Report
• MBRRACE-UK - publications

Saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18

MBRRACE-UK -
This report examines the care received by women who die during or up to a year after pregnancy and covers all pregnancy-associated deaths involving UK women between 2016 and 2018. The results indicate that whilst maternal death is still rare in the UK, there are some important actions identified to prevent women from dying in the future.

• Report
• MBRRACE-UK - publications

Support for staff following patient safety incidents

Healthcare Safety Investigation Branch -
This report explores feedback from national investigators around positive efforts identified in the support of NHS staff by their organisations following patient safety incidents. It describes the literature around NHS staff support to attempt to identify areas of best practice and the impact of any interventions.

• Report
• Healthcare Safety Investigation Branch - publications