Ep 12 - The NCEPOD Common Themes 2024 Report
Show notes
The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) - Common Themes 2024 Report
The NCEPOD Common Themes Report was first published in 2018 as a “living report” of key topics to be discussed in the care of hospital patients. It was subsequently updated in 2024 to the current edition with a stronger focus on communication, transition planning, and follow-up.
Common Thread: health care often does not fail due to technical proficiency, rather, it fails due to lack of teamwork, weak communication, poor documentation, and delayed recognition of deterioration.
Common Theme 1: Multidisciplinary Reviews
Liaison with all health care teams, including medical, nursing, physiotherapy, dietitians, social work, discharge planners, and home care, can improve quality of care and prevent patient harm.
Common Theme 2: Communication with Family, Parents, and Carers
Caregivers should be kept informed and involved within reason in correspondence with patient wishes and to facilitate safe discharge.
Common Theme 3: Consent
It remains difficult to provide appropriate informed consent when discussing relative risks and benefits with patients and their families. Nevertheless, it is up to the healthcare team conducting the procedure or investigation to adequately inform the patient about their options.
Common Theme 4: Monitoring and Early Warning Signs
Tools such as the National Early Warning Score (NEWS2) or other validated standardized approaches may facilitate identification of patients who need rapid response and monitoring.
Common Theme 5: Documentation
Reports are essential as legal documentation and to facilitate good care. Documentation is to be legible, accurate, up-to-date, and signed by the practitioner.
Common Theme 6: Transition Planning
A “transition” to adult service pathway is necessary in a child graduating to adult care.
Common Theme 7: Clinical Networks
Clinical networks emphasizing collaboration between health professionals and organizations at all levels of primary, secondary, and tertiary care aid in providing a clear pipeline for complex medical issues (e.g. provincial cancer centres).
Common Theme 8: Local Policies, Protocol, Proforma, and Guidelines
Documents outlining an approach to most general medical situations (e.g. diabetic ketoacidosis, nicotine replacement therapy, inpatient insulin orders) provide standards of care and ensure comprehensiveness in treatment.
Most of these documents are not used because health professionals don’t know they exist.
Common Theme 9: Follow-up Post Discharge
“Discharge planning starts the day of admission."
It is essential that patients and their caregivers receive a comprehensive summary of their hospital stay, their diagnoses, self-management plans, changes to medication, follow-up plans, and when to return for urgent assessment.
Safety Intervention Worth Mentioning: NCEPOD reports
The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) - Common Themes 2024 Report
Random recommendations
Adam: CBC’s The Expert Witness from Uncover and watch out for CBC’s See You in Court (Season 2) podcast.
Amir: Journal for both positive and negative emotions in your life
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