Learning from Patient Safety Incidents

It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated.  Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.

National Patient Safety Alerts relevant to intensive care

National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.mhra.gov.uk/Home.aspx).

Regulation 28 Reports to Prevent Future Deaths

The Faculty receives reports from the Chief Cororoner where it is believed action should be taken to prevent future deaths. Those relevant to Intensive Care Medicine will be published here. 

Regulation 28 Report: Pathway for urgent neurosurgical procedures (February 2017)

Regulation 28 Report: Air embolism (April 2018)

Lessons from adverse incidents

Lessons from local incidents may not be shared widely and to improve wider patient safety, the Professional Affairs and Safety (PAS) Committee of the Faculty has developed this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.

We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence. The forms should be sent to contact@ficm.ac.uk. 

Local Patient Safety Incident Form

SAFETY MATTERS: Local Incident Lessons

Endotracheal Tube Revision on the ICU

Stroke following central venous line

Accidental phenytoin overdose

Manual bolus dose of insulin

Incorrect connection of epidural infusion 

Retained foreign object post procedure

Vascath Stylet Fault