2 Sep 2008Hand hygiene Patient Safety Alert Significant improvement has been made in hand hygiene practice over the last four years. The NPSA has reviewed its NRLS strategy, vision, goals and objectives and has started to put in place significant changes in order to improve the collection and analysis of patient safety data. 10A pilot should be established to examine the option of the National Institute for health and Clinical Excellence (NICE) developing technical patient safety solutions. The NPSA is working with the NHS Institute for Innovation and Improvement on training programmes for patient safety. A joint project has been established between NPSA and Action Against Medical Accidents (AvMA) to develop the role and responsibilities for patient safety champions. Patient Safety DirectPatient Safety Direct is in the start up phase—scoping the issues and developing the business case.
A number of current functions, for example the development of technical solutions to improve patient safety, presently delivered by the organisation should in future be commissioned from other expert organisations with the requisite expertise. Importantly, each initiative should also make clear how it intents to ensure that patients and carers play an integral part in all initiatives to introduce a patient safety culture change within the NHS.


18 Sep 2008NHS Number Safer Practice Notice Mis-identification is a known risk in healthcare.
5The core purpose of the National Reporting and Learning System (NRLS) should be to identify sources of risk and harm to patients which can be acted upon at local and national level.
11The NHS Institute for Innovation and Improvement should be asked to work with the medical Royal Colleges and other education providers to ensure that advances are made and training to support patient safety.
Using the NHS Number as the national patient identifier; (or the NHS Number in conjunction with a local hospital numbering system) can reduce the number of times patients are wrongly identified.
Every NHS organisation should have access to a specialist investigator based within the Patient Safety Action Team. Due to the positive progress the NPSA has been informed that it will continue to develop and disseminate solutions to improve patient safety.
3The National Patient Safety Forum should oversee the design and implementation of a national patient safety campaign-focused initiative. The patient safety managers (28) in England were transferred to SHAs to be core members of the SHA patient safety action teams as of 1 April 2009.


The Agency is also working with the campaign team to help them deliver the key leadership intervention to make patient safety the highest priority for NHS organisations.
The NPSA in partnership with the NHS Institute for Innovation and Improvement and The Health Foundation designed a patient safety campaign strategy.
The NPSA has developed refined tools and techniques to help patient safety action teams support local organisations with their incident investigations.
However, to maintain this and other improvements it is vital that hand hygiene remains high on the patient safety agenda. 4The role of the National Patient Safety Agency (NPSA) should be refocused on its core objective of collecting and analysing patient safety data to inform rapid patient safety learning, priority setting and coordinate activity across the NHS. 8Accountability for patient safety rests with the Chair and Board of each NHS organisation.



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