The UKKA Kidney Patient Safety Committee (KPSC) is a multi-professional group which meets monthly to review kidney patient safety incidents and risks. Kidney Care units are encouraged to continue to report any incidents through their Trust reporting systems, but the KPSC is also very willing to discuss any concerns you may have about patient safety. https://ukkidney.org/patient-safety-reporting-form
The UKKA is also represented on the Royal College of Physicians Patient Safety Committee, and recently a number of reports and initiatives relating to generic patient safety have been noted, which apply to kidney healthcare.
The Patient Safety Commissioner has set out the 7 Patient Safety Principles, https://www.patientsafetycommissioner.org.uk/wp-content/uploads/2024/10/PSP-A3-Principles.pdf
1.Create a culture of safety
2. Put patients at the centre of everything
3. Treat patients equitably
4. Identify and act on inequalities
5. Identify and mitigate risks
6. Be transparent and accountable
7. Use information and data to drive improved care and outcomes.
We can learn from how safety management systems operate in other industries. The Health Services Safety Investigations Body (HSSIB) has published an overview: https://www.hssib.org.uk/patient-safety-investigations/safety-management-systems/
They have also produced a video: https://www.youtube.com/watch?v=3Ut-Gofs3TE
All of us must consider how the findings of safety reports are recognised, shared and implemented in kidney care units, in order to change practice. The HSSIB will be working to address the issue of: “Recommendations but no action,” in order to improve the effectiveness of quality and safety recommendations.
Fatigue is a risk in healthcare and can impact on patient safety and is being investigated by the HSSIB; https://www.hssib.org.uk/patient-safety-investigations/fatigue-risk-in-healthcare-and-its-impact-on-patient-safety/launch-report/
Other safety issues that apply to kidney care units and inpatient wards have been identified by the HSSIB, who have launched investigations:
Medication related harm, from delayed or missed medication
Recognition of sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
Professor Paul Rylance on behalf of the KPSC