Safety recommendation
NHS Improvement amends the national Prosthesis Verification Standard to incorporate the specific aspects of verification practice developed to mitigate error identified in this investigation.
Response:
The national Prosthesis Verification Standard is one of thirteen standards identified in the National Standards for Invasive Procedures (NatSSIPs) published in September 2015. NHS Improvement established a NatSSIPs Reference Group when the standards were originally developed which continues to meet. It was recognised when the NatSSIPs were launched that these standards would require regular review and update to reflect current practice and the Terms of Reference for the Reference Group are currently being revised to incorporate this requirement within it’s remit.
This safety recommendation will be brought to the attention of the NatSSIPs reference group for consideration with a view to an amendment being issued to the current version of NatSSIPS. The amendment will be issued on the NHS Improvement website and promoted through the NHS Improvement Bulletin and shared with the relevant Royal Colleges and professional associations.
The next NatSSIPs reference group meeting is planned for 23 October 2018 so the amendment will be published by 31 October 2018. There is currently a thematic review into Never Events, commissioned by Secretary of State for Health and Social Care, being undertaken by CQC with the support of NHS Improvement which is expected to report in Autumn 2018 and potentially make recommendations regarding the contents of the NatSSIPs. A revised version of the NatSSIPs will be published by Summer 2019 to provide time to also incorporate any additional actions identified from the thematic review and other sources of intelligence that have been brought to the attention of the Reference Group.
Response received on 11 July 2018.