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National Patient Safety Agency

NPSA outlines ways to improve patient safety for children and young people

Wednesday 17 June 2009


The National Patient Safety Agency (NPSA) is calling on health practitioners and staff across England and Wales to follow recommendations, issued today (17 June), to improve patient safety for children and young people.


The advice follows the publication of the Review of Patient Safety for Children and Young People, unveiled by the NPSA.


One of the key findings in the report, which looked at incidents that occurred between October 2007 and September 2008, was that there was a high rate of medication administration dosing errors, in particular in children under the age of four.  


NPSA’s Medical Director, Dr Kevin Cleary, said: “The majority of patient safety incidents involving children were reported to have resulted in no harm or low harm.


“However we’re hoping this constructive feedback will support all trusts and clinicians in delivering even safer clinical care to all NHS patients in the future.”


Dr Cleary added: “We are urging all trusts and healthcare providers to follow our recommendations and use the tools described within the report. 


“Examples include the Seven Steps to Patient Safety and the Manchester Patient Safety Framework – both designed to help organisations measure and improve progress towards making patient safety a central focus.


“I would also like to remind all practitioners and staff about our Patient Safety First campaign.  This initiative, launched last year, aims to increase awareness about how to reduce instances of harm to patients through effective leadership and training.”


Read the Review of Patient Safety for Children and Young People.






Notes to Editors:


Media enquiries to the NPSA Press Office:



The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.


Other findings from the report revealed:


  • difficulties associated with the recognition of the severity of illness in children;

  • an under-reporting of patient safety incidents in primary care;

  • a stronger approach to addressing healthcare associated risks that children or young people might face, integrating health, social care and education;

  • a lack of recognition and appropriate management of young people with mental health problems.  This includes the provision of a safe and appropriate inpatient environment for care and treatment.


The NPSA used information from the 910,000 patient safety incidents that had been reported over the past year (60,000 of these involved children), as well as direct feedback from children, young people and their families.  The NPSA also reviewed studies and policy documents as well as evidence from the country’s leading doctors, nurses and professional groups before writing their recommendations.


The NPSA has a number of tools and resources available to support organisations to understand and to make changes to their working practices and safety culture with the aim of reducing harm to patients.


These tools include:


  • Seven steps to patient safety – a best practice guide to key areas of activity to ensure patient safety is being addressed in an individual organisation.

  • The Manchester Patient Safety Framework (MaPSaF) – a tool that helps organisations measure their progress towards making patient safety a central focus within an organisation.

  • Being open – the NPSA’s Being Open policy and tools helps healthcare staff communicate honestly and sympathetically with patients and their families when things go wrong.

  • Root cause analysis (RCA) – the RCA toolkit provides a framework for reviewing patient safety incidents. Investigations can identify what, how, and why patient safety incidents have happened. Analysis can then be used to identify areas for change, develop recommendations and look for new solutions.

  • Incident Decision Tree (IDT) – the IDT tool has been created to compliment the NPSA’s RCA toolkit and to help NHS managers and senior clinicians decide whether they need to suspend/exclude staff involved in a serious patient safety incident and to identify appropriate management action.

  • Foresight Training – this resource pack has been developed to improve awareness in nursing and midwifery of the factors that combine to increase the likelihood of patient safety incidents. The pack contains a range of training scenarios, paper and video-based and supporting materials for use by a facilitator.