Patient safety incidents associated with failures in communication reported from critical care units in the North West of England between 2009 and 2014
March 23, 2016Source: Journal of the Intensive Care Society [Epub ahead of print]
Date of publication: February 2016
Publication type: Journal article
In a nutshell: Communication is central to the safe and effective delivery of critical care. This article presents a retrospective analysis of hospital incident reports attributed to communication that were generated by 30 intensive care units in the North West of England from 2009 to 2014. The study reviewed when during the critical care pathway incidents occur, the personnel involved, the method of communication used, the type of information communicated and the level of harm associated with the incident. The study found that patient safety incidents tend to occur when patients are transferred into or out of the intensive care unit and when information has to be communicated to other teams during the critical care stay. Ways that the patient handover process may be modified to improve communication and safety are also examined.
Length of publication: 1 webpage
The commission on education and training for patient safety: improving patient safety through education and training
March 23, 2016Source: Health Education England
Date of publication: March 2016
Publication type: Report
In a nutshell: Produced by the Commission on Education and Training for Patient Safety and supported by Imperial College the report sets out ambitions, the case for change, what is working well including case studies and where improvements need to be made to make the greatest difference to patient safety both now and in the future. It sets out the future of education and training for patient safety in the NHS over the next ten years, making twelve recommendations to Health Education England and the wider system.
Length of publication: 60 pages
Safety standards for invasive procedures: beware the implementation gap
March 23, 2016Source: BMJ 352:i1121
Date of publication: February 2016
Publication type: Journal article
In a nutshell: Nick Sevdalis is professor of implementation science and patient safety at King’s College London. In this editorial he offers advice regarding the implementation of the recent NHS England guideline National Safety Standards for Invasive Procedures (NatSSIPs).
Length of publication: 2 pages
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
Simulation-based training: the missing link to lastingly improved safety and health?
March 23, 2016Source: Postgraduate Medical Journal [Epub ahead of print]
Date of publication: February 2016
Publication type: Journal article
In a nutshell: Medical education has traditionally relied on on-the-job training. However, the often used ‘see one, do one, teach one’ approach may be detrimental to patient safety and health, as it exposes patients to inexperienced healthcare practitioners. In an effort to reduce human errors and improve operational safety, simulation-based training (SBT) has been recognised as an effective methodology.
Contents of SBT include conceptual understanding, technical skills, decision-making skills, and attitudes and behaviours summarised as teamwork. Thus, theoretical advantages of SBT over traditional educational methodologies are manifold. This article reviews available evidence about the effectiveness of SBT of technical and non-technical skills with regard to improvements in medical care, patient safety and health.
Length of publication: 3 pages
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process
March 23, 2016Source: BMJ Quality & Safety [Epub ahead of print]
Date of publication: February 2016
Publication type: Journal article
In a nutshell: Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. This study used a Delphi approach to determine consensus regarding the ideal role of PSRSs and to devise recommendations for best practice.
The study resulted in reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.
Length of publication: 14 pages
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
Researchers’ roles in patient safety improvement
March 23, 2016Source: Journal of Patient Safety 12/1 pp. 25–33
Date of publication: March 2016
Publication type: Journal article
In a nutshell: This article explores how researchers can contribute to patient safety improvement with the aim of expanding the instrumental role researchers have often occupied in relation to patient safety improvement.
The conclusions were that when working side by side with “practice,” researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds—as well as other actors involved in patient safety improvement—in structuring their work and collaborating productively.
Length of publication: 9 pages
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
The daily relationships between staffing, safety perceptions and personality in hospital nursing: a longitudinal on-line diary study
March 23, 2016Source: International Journal of Nursing Studies 59 pp. 27–37
Date of publication: March 2016
Publication type: Journal article
In a nutshell: The association between poor staffing conditions and negative patient safety consequences is well established within hospital nursing. However, many studies have been limited to nurse population level associations, and have used routine data to examine relationships. As a result, it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis. Furthermore, personality may have direct and moderating roles in terms of work environment and patient safety associations, but limited research has explored personality in this context.
The findings elucidate the potential mechanisms by which patient safety risks arise within hospital nursing, and suggest that nurses may not respond to staffing conditions in the same way, dependent upon personality. Further understanding of these relationships will enable staff to be supported in terms of work environment conditions on an individual basis.
Length of publication: 11 pages
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
Patient safety and the problem of many hands
March 23, 2016Source: BMJ Quality & Safety [Epub ahead of print]
Date of publication: February 2016
Publication type: Journal article
In a nutshell: Healthcare worldwide is faced with a crisis of patient safety. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. The authors of this article propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors—organisations, individuals, groups—each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. This paper calls for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.
Length of publication: 5 pages
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
Improving the safety of vaccine delivery
March 23, 2016Source: Human Vaccines & Immunotherapeutics [Epub ahead of print]
Date of publication: February 2016
Publication type: Journal article
In a nutshell: Vaccines save millions of lives per annum and are an integral part of community primary care provision worldwide. The World Health Organization has highlighted that the adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst it is known that as many as one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and drug adverse event surveillance systems are proving useful informants for understanding the underlying causes of those errors. The challenge now lies in the identification and implementation of changes to improve vaccine safety at multiple levels: from patient level interventions through to organisational efforts at local, national and international levels. The authors consider the potential benefits for maximising learning from patient safety incident reports to improve the quality and safety of care delivery.
Length of publication: Unspecified
Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library
The UK: your partner for global healthcare solutions – Improving the quality and safety of patient care
March 23, 2016Source: Department of Health
Date of publication: March 2016
Publication type: Brochure
In a nutshell: In 2014 the Commonwealth Fund named the NHS as the number one health service for safe care amongst the 11 developed nations studied. The NHS is aiming for a future where avoidable harm is prevented, where 100% of patients achieve the shortest, most uneventful hospital admissions, and where everyone achieves the best possible outcome.
This publication outlines some of the initiatives the UK is currently pursuing, and the organisations which are leading the way in standards of safety. The different sections also provide information on the partners who can best help you achieve your goal of safer, better healthcare.
Length of publication: 15 pages