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Platform 6: Improving safety and quality of care

Patient safety, incident reporting, safeguarding

Key Tip

Safeguarding question pattern: a patient discloses abuse and asks you to keep it secret → answer is always to act on the safeguarding concern. A request for confidentiality does not override a duty to safeguard. Document the disclosure and your actions immediately.

Core Clinical Guidance

Never Events

Wholly preventable serious incidents. Examples: wrong-site surgery · wrong-route medication (e.g. IV potassium chloride undiluted) · retained surgical item · ABO-incompatible blood transfusion · overdose of methotrexate due to daily instead of weekly dispensing.

Datix reporting

NHS digital incident reporting system. All adverse events AND near misses should be reported. Blame-free — purpose is learning and system improvement, not punishment. Incident reports are not part of the clinical record.

Safeguarding adults — 6 categories

Physical · Sexual · Psychological/emotional · Financial/material · Neglect and acts of omission · Discriminatory abuse. Legal framework: Care Act 2014.

PREVENT duty

Part of the Counter-Terrorism and Security Act 2015. Healthcare workers have a duty to refer individuals showing signs of radicalisation to the PREVENT team. Confidentiality applies unless risk of harm.

CQC — 5 key questions

Is care Safe · Effective · Caring · Responsive · Well-led? Ratings: Outstanding / Good / Requires Improvement / Inadequate. The CQC can close services rated Inadequate.

Sepsis red flags (adults)

Slurred speech or confusion · Extreme shivering or muscle pain · Passing no urine in a day · Severe breathlessness · Skin mottled, discoloured or very pale · Feeling you might die.

Medication error response

(1) Ensure patient safety — assess for harm (2) Report immediately to nurse in charge (3) Complete Datix report (4) Inform patient — duty of candour (5) Document in patient notes (6) Review to learn and prevent recurrence.

RIDDOR

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. Employers must report: workplace fatalities, specified injuries to workers, over-7-day incapacitation, and dangerous occurrences.