Paediatric early warning score systems are used for early detection of clinical deterioration of patients in paediatric wards. Several paediatric early warning scores have been developed, but most of them are not suitable for children with cyanotic CHD who are adapted to lower arterial oxygen saturation.

The present study compared the original paediatric early warning system of the Royal College of Physicians of Ireland with a modification for children with cyanotic CHD.

Retrospective single-centre study in a paediatric cardiology intermediate care unit at a German university hospital.

The distribution of recorded values showed a significant shift towards higher score values in patients with cyanotic CHD (p < 0.001) using the original score, but not with the modification. An analysis of sensitivity and specificity for the factor “requirement of action” showed an area under the receiver operating characteristic for non-cyanotic patients of 0.908 (95% CI 0.862–0.954). For patients with cyanotic CHD, using the original score, the area under the receiver operating characteristic was reduced to 0.731 (95% CI 0.637–0.824, p = 0.001) compared to 0.862 (95% CI 0.809–0.915, p = 0.207), when the modified score was used. Using the critical threshold of scores ≥ 4 in patients with cyanotic CHD, sensitivity and specificity for the modified score was higher than for the original (sensitivity 78.8 versus 72.7%, specificity 78.2 versus 58.4%).

The modified score is a uniform scoring system for identifying clinical deterioration, which can be used in children with and without cyanotic CHD.

To evaluate the quality of prescription writing in the context of public primary health care.

Prescription errors are one of the leading patient safety problems in primary care and can be caused by errors in therapeutic decisions or in the quality of prescription writing.

Cross-sectional observational study conducted in a municipality in Northeastern Brazil. The assessment instrument (including 13 indicators and one composite indicator) was applied to a representative sample of drug prescriptions from the 24 Family Health Teams providing Primary Health Care in the municipality, dispensed in January 2021. Estimates of compliance and their 95% confidence intervals and graphical analysis of frequencies are assessed globally and stratified by dispensing units and prescribers.

The average composite prescription writing quality on a 0-100 scale was 60.2 (95% CI 57.8–62.6). No quality criteria had 100% compliance. The highest compliance rates were found for ‘frequency of administration’ (98.9%) and ‘identification of the prescriber’ (98.9%). On the other hand, ‘recorded information on allergy’ (0.0%), ‘patient’s date of birth’ (1.7%), ‘nonpharmacological recommendations’ (1.7%), and ‘guidance on the use of the drug’ (25%) were the indicators with lower compliance, contributing to 69% of the noncompliances found. The type and frequency of the errors in the quality of prescription writing uncovered in this study confirm the continuing need to tackle this problem to improve patient safety. The results identify priority aspects for interventions and further studies on the quality of prescription writing in the context of Primary Health Care in Brazil.

During the coronavirus disease 2019 pandemic, ENT-UK recommended a move from face-to-face clinics to telephone appointments. This study reviewed the safety of telephone clinics for urgent two-week-wait cancer referrals.

Patients consulted in telephone clinics between April and November 2020 were identified from an electronic database. Study patients included those diagnosed with malignant disease at six months. The Head and Neck Cancer Risk Calculator version 2 score, outcome of the initial clinic and final diagnoses were reviewed.

A total of 1062 patients were triaged in clinic; 9.2 per cent (n = 98) were diagnosed with cancer at 6 months. Of these 98 patients, 69 received an urgent face-to-face appointment, 26 underwent urgent scans and 3 had a delayed telephone review. Twenty patients (20.4 per cent) diagnosed with cancer had a low-risk Head and Neck Cancer Risk Calculator score.

The late diagnosis rate of 0.28 per cent suggests a small proportion of cancer could have been missed. Telephone clinics, whilst a pragmatic means to maintain patient flow during the pandemic, could result in late diagnoses.

Radiotherapy is an ever-changing field with constant technological advances. It is for this reason that risk management strategies are regularly updated in order to remain optimal.

A retrospective audit of all reported incidents and near misses in the audited department between 1 November 2020 and 30 April 2021 was performed. The root cause of each radiotherapy error (RTE), safety barrier (SB) and the causative factor (CF) would be defined by the Public Health England (PHE) coding system. The data will then be analysed to determine if there are any frequently occurring errors and if there are any existing relationships between multiple error.

670 patients were treated during the study period along with 35 reports generated. 77·1% (n = 27) were incidents, and 22·9% (n = 8) were near misses. 2·8% (n = 1) were reportable incidents. The ratio of RTEs to prescriptions was 0·052:1 (5·2%). 37% of RTEs were associated with image production. Slips and lapses were involved in 54·2%. Adherence to procedures/protocols was a factor in 48·5% (n = 17). Communication was a factor in 11·4% (n = 4).

The proportion of Level 1 incidents was higher in this department (2·8%) than in the PHE report (0·9%). Almost one-third, 31·4% (n = 11) of errors stemmed from one technical fault in image production. SB breaches were prevalent at the pre-treatment planning stage of the pathway. A relationship between slips/lapses and non-conformance to protocols was identified.

The rate of reported radiotherapy incidents in the UK is lower when compared with this department; this could be improved with the implementation of the quality improvement plan outlined above.

Patient safety problems stemming from healthcare represent a significant cause of morbidity and mortality globally. The evidence base on safety in mental healthcare, particularly regarding community-based mental health services, has long fallen behind that of physical healthcare, with fewer research publications, developed primarily in isolation from the wider improvement science discipline. This disconnect both yields, and stems from, conceptual and practical challenges which must be surmounted in order to advance the science and improvement of safety in mental healthcare.

The objectives of this research were to conduct a narrative review to provide an overview of conceptual issues in this area, their origins, and implications for patient safety science and clinical care. We also sought to identify approaches to overcoming these issues.

We examined theoretical and empirical evidence from the fields of patient safety, mental health, and improvement science to address this knowledge gap.

We identified challenges with defining safety in the context of community mental healthcare, ascertaining what constitutes a ‘preventable’ safety problem requiring intervention, and in finding relevant research evidence. The research indicated that risk management has taken precedence over proactive safety promotion in mental healthcare. This positions service users as the origin of safety risks, with iatrogenic harm and latent system hazards associated with mental healthcare widely overlooked.

We propose a broader conceptualisation of safety to advance the field and outline potential next steps for the integration and uptake of different sources of ‘safety intelligence’ within community mental health services.

NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

There is limited existing research about patient safety issues in mental healthcare. A lack of evidence is particularly pronounced in relation to safety in community-based mental health services, where the majority of care is provided. To date, reviews of mental health patient safety literature have focused primarily on inpatient care settings.

This systematic scoping review will aim to identify and synthesise literature about the types of patient safety problems in adult community-based mental health settings, the causes of these problems, and evaluated safety interventions in this care context.

A systematic search was conducted on 19th June 2020 and refreshed on 23rd October 2021, across five databases: Medline, Embase, PsycINFO, Health Management Information Consortium, and Cumulative Index to Nursing and Allied Health Literature. The search strategy focused on three key elements: ‘mental health’, ‘patient safety’ and ‘community-based mental health services’. Retrieved articles were screened at title, abstract and subject heading level, followed by full-text screen of longlisted articles.

In this presentation, the findings of this systematic scoping review will be described, based on synthesised literature about safety incidents, broader care delivery problems, their causes, and evaluated patient safety interventions to address these issues.

This study will offer learning opportunities about the safety problems, contributory factors, and safety interventions in adult community-based mental health services, as described in the evidence base. Review findings will also help to ascertain gaps in existing research, which should be addressed in future studies.

NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

Existing research has seldom examined patient safety problems experienced by service users accessing community mental healthcare, with the growing evidence base focusing largely on safety in psychiatric inpatient settings. Accordingly, there is poor understanding of safety issues in community-based mental health services as perceived by service users, carers, and healthcare professionals.

This study aims to explore safety problems in adult community-based mental health services, their causation, and priority areas for improving the safety of care provided in these services.

In-depth, semi-structured interviews and focus groups were conducted with users of community-based mental health services, carers, and healthcare professionals employed within these settings. Interview topic guides were designed jointly with stakeholders from these groups (N=7) and piloted (N=3). Interviews and focus groups will be transcribed, coded, and analysed using an inductive thematic analysis approach. Illustrative quotes will be extracted and used to describe the key themes that emerge from the analysis and their inter-relationships.

This presentation will provide an outline of patient safety as understood and experienced by key stakeholder groups. Study findings will explicate safety issues, healthcare system factors underpinning their causation, as well as practices which could improve safety in this context.

This research will help to advance understanding of the nature of patient safety problems in community-based mental healthcare services for adults, based on the experiences of service users, carers, and healthcare professionals within these services. The research will address key evidence gaps and represents an important step towards identifying areas which warrant intervention to improve patient safety.

NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

SIDS is the sudden, unexpected and unexplained death of a baby. Safe sleeping practices can help to reduce a baby’s risk of SIDS. At the Coombe Wood Mother & Baby Unit (MBU), it was found that many patients were opting to co-sleep with their babies which contradicts safe sleeping guidelines.

To improve patient awareness of the condition SIDS and to implement an interactive training session improving awareness of safe sleeping practices for babies. To improve patients’ confidence in implementing safe sleeping practices for their babies; thus reducing the risk of SIDS occurring.

The Lullaby Trust™ is a charity that raises awareness of SIDS and provides expert advice on safe sleep for babies. An interactive training session for patients was organised by incorporating published materials from The Lullaby Trust™, facilitated by medical and occupational therapy staff on the MBU. The participants filled out a pre-training and post-training questionnaire to test the effectiveness and quality of the training session.

The participants’ average level of confidence in knowing and applying safe sleeping practices for their babies doubled following the training session (from 2.3→4.8 and 2.6→5 respectively, with 5 meaning “Very Confident.”) The average level of knowledge of SIDS also increased from 1.6→4.4 (with 5 meaning “A Lot” of Knowledge.)

We were surprised at the low level of knowledge and confidence the patients had regarding safe sleeping practices for their babies. This project shows how interactive, ward-based training can be an effective way to engage and stimulate patients into improving the safety of their baby care.

No significant relationships.

Healthcare workers are at higher risk of suicide than other occupations, and suicidal thoughts appear to have increased during the COVID-19 pandemic.

To understand the experiences of healthcare workers with frequent thoughts of suicide or self-harm during the pandemic, including factors that contributed to their distress, and the supports that they found helpful.

We used content analysis to analyse free-text responses to the Australian COVID-19 Frontline Healthcare Workers Study, from healthcare workers who reported frequent thoughts that they would be better off dead or of hurting themselves, on the Patient Health Questionnaire-9.

A total of 262 out of 7795 healthcare workers (3.4%) reported frequent thoughts of suicide or self-harm in the preceding 2 weeks. They described how the pandemic exacerbated pre-existing challenges in their lives, such as living with a mental illness, working in an unsupportive environment and facing personal stressors like relationship violence or unwell family members. Further deterioration in their mental health was triggered by heavier obligations at home and work, amid painful feelings of loneliness. They reported that workplace demands rose without additional resources, social and emotional isolation increased and many healthful activities became inaccessible. Tokenistic offers of support fell flat in the face of multiple barriers to taking leave or accessing professional help. Validation of distress, improved access to healthcare and a stronger sense of belonging were identified as helpful supports.

These findings highlight the need for better recognition of predisposing, precipitating, perpetuating and protective factors for thoughts of suicide and self-harm among healthcare workers.