Patient Safety Horizon Scanning Volume 7 Issue 3

March 23, 2016

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, 2016

Source:  Journal of the Intensive Care Society [Epub ahead of print]

Follow this link for item

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, 2016

Source:  Health Education England

Follow this link for item

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, 2016

Source:  BMJ 352:i1121

Follow this link for abstract

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, 2016

Source: Postgraduate Medical Journal [Epub ahead of print]

Follow this link for abstract

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, 2016

Source:  BMJ Quality & Safety [Epub ahead of print]

Follow this link for abstract

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


Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety

March 23, 2016

Source: Surgical Endoscopy [Epub ahead of print]

Follow this link for item

Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Answering telephone calls and pagers is common distraction in the operating room. This study sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance.

The study found that distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents’ ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

Length of publication:  6 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