Managing 8 hospitals, Gloucestershire Care Services NHS Trust provides medical services to the approximately 600,000 people living in the county.
The trust provides specialist services including sexual health, heart failure, community dentistry and tissue viability.
All NHS Trusts are obliged to report any occurrence of a Patient Safety Incident, which are defined as “any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS-funded healthcare” (Guidance notes on NRLS official statistics publications – September 2017).
These encompass a wide range of types of incident including medication or prescription errors, pressure ulcers, medical device or equipment failures and surgical errors, among many others. All Patient Safety Incidents are recorded against the level of harm that occurred as a result, ranging from no harm through to death. The defined levels of harm are:
No harm – Where no harm or damage was caused to the patient
Low harm – Extra observation or treatment was required as a result of the incident
Moderate harm – Requiring extra treatment including extra surgical intervention, cancelling treatment, transfer to another area and short-term harm as a result of the incident
Severe harm – Permanent or long-term harm as a result of the incident
Death – Where death has occurred as a result of the incident
Patient Safety Incident data is published twice a year and can be found on the NHS Improvement website at: https://improvement.nhs.uk/resources/organisation-patient-safety-incident-reports-22-march-2017/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.
Whenever a Patient Safety Incident occurs the NHS Trust must also record the category (nature) of the incident against a list of 11 defined categories. The same categories of incident apply to acute, community and acute specialist trusts and range from clinical assessment (including diagnosis, scans, tests, assessments) to medical device/equipment or the implementation of care and ongoing monitoring/review. A similar but slightly different list of categories applies to mental health trusts and includes incidents such as disruptive, aggressive behaviour; self-harming behaviour and consent; communication and confidentiality.
Here we show the top 3 most commonly recorded categories by the individual Trust during the six-month time period for which this data relates to.
Patient Safety Incident data, including the list of categories, is published every six months and can be found on the NHS Improvement website at: https://improvement.nhs.uk/resources/organisation-patient-safety-incident-reports-22-march-2017/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.
The NHS define Never Events as “patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. Each Never Event has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event” (Never Events Policy and Framework, revised January 2018, NHS Improvement).
Never Events are considered to be the most serious incidents, which should in theory never occur if proper guidelines are followed. Any occurrence of a Never Event should be reported by the NHS Trust and an investigation followed in order to ensure steps are identified to prevent any future occurrence of a Never Event. Never Events can arise from a variety of situations and the NHS have devised a clear framework detailing the exact categories of incident that constitute a Never Event. These 15 categories are shown in the data presented on this site, as is the number of each incident type that has occurred during the relevant time period.
Never Events data is available quarterly and can be found on the NHS Improvement website at: https://improvement.nhs.uk/resources/never-events-data/. This data is public sector information licensed to Blackwater Law under the Open Government Licence v3.0: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/.