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Published in June 2009 by the National Patient Safety Agency (NPSA), the review of patient safety for children and young people highlights some of the patient safety issues for children, young people and their families, outlines current NPSA partnership work streams, and identifies key actions for stakeholders.
Action
As a result of this review healthcare professionals should:
- Ensure they and their organisations are using NPSA tools effectively
- Encourage reporting of incidents (especially from primary care settings)
- Register for the Patient Safety First Campaign
- Check the review for additional relevant action points
Background
The report states that each year there are approximately 1.9 million hospital admissions of children under 14 years in England and Wales and approximately 46 million contacts by children with general practice services. Given that the most common therapeutic intervention given in the NHS is medicines (MeReC Bulletin vol12 No6, NPC), it is important for healthcare professionals to be aware of the tools and resources available to help them ensure these medicines are prescribed, dispensed and used in as safe a way as possible.
Summary
The NPSA used a variety of sources, such as their own report and learning system (RLS), key patient safety quantitative studies and external stakeholder consultations, to build a comprehensive picture of patient safety issues for children and young people. The most common incident type reported for children was medication incidents, making up 17% of all reported incidents for this group. In neonates medication incidents was the second most common incident type making up 15% of all reported incidents for this group. Of these medication incidents the most common type of incident was administration of the incorrect dose or strength of medication.
The NPSA identified, from commissioned research they undertook involving the National Children’s Bureau (NCB) and the Common Assessment Framework (CAF) in 2007, that effective communication and listening skills involving age-appropriate language, and the provision of full and clear explanations about their diagnosis, treatment and medication helped children to feel safe in a healthcare environment. The communication skills of healthcare professionals are paramount when providing healthcare as they allow professionals to build effective relationships with people resulting in improved prescribing and a greater level of adherence and understanding from patients.
As well as highlighting findings, this report also gives a number of action points for organisations and individuals to take such as:
- Using NPSA tools and resources (such as Seven Steps to Patient Safety)
- Reviewing local standard operating procedures for medicines management
- Ensuring staff meet National Service Framework standards
- Register for the Patient Safety First Campaign
What does this mean to medicines management?
This publication will be of particular interest to those providing health services to children in acute, primary care and third sector settings, as well as those providing neonatal services, and provides some key action points for stakeholders. The report highlights that only 4% of reported incidents involving children were from primary care settings, which may indicate under-reporting. As the vast majority of children receive their healthcare in the community it is essential that, if you work in this area, you encourage the reporting of incidents to allow learning from these to take place. Two key findings from the review were the lack of effective communication by healthcare professionals and the number of incidents involving medicines. People working with medicines or within a medicines management team need to review the work they carry out on a regular basis and ensure any problems within their own area or organisation are identified and acted upon.
NPC has resources covering a number of topics that may be useful if you are looking for further information or wish to make improvements to patient safety within medicines management. Two of the key topics are:
The NPSA also have a range of resources and information available via their website.
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