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Evaluation of NPSA Patient Safety Observatory Reports

Researchers: Annette Lankshear and Karin Lowson (University of York)

Patient Safety Observatory Reports are themed analyses of adverse incidents reported by the NHS to the National Reporting and Learning System.  They fulfill the intention of ensuring that NHS Trusts can learn from each other and optimise patient safety.  The reports are well produced, glossy publications which are sent to specific people in Trusts in England and Wales.  We sought to determine how the information contained within two of the reports - Safety in Doses (PSOR 4) and Safer Care for the Acute Ill Patient (PSROR5) - had been used and to assess the views of stakeholders on the format.  We found that the reports are difficult to share and almost impossible to track within organisations.  Pharmacists found little new material in PSOR4 and the simultaneous publication of NICE guidance with PSOR5 appeared to overshadow it.  We found no evidence of reference to the document in key minutes.  However, most Trusts had adopted many of the key recommendations such as the adoption of the early warning systems and the establishment of critical care outreach teams, although few of these operated a 24/7 service.