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]

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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

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Improving the safety of vaccine delivery

March 23, 2016

Source:  Human Vaccines & Immunotherapeutics [Epub ahead of print]

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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


Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

February 24, 2016

Source:  Applied Ergonomics Jan/52 pp. 185-95

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

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


Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data

January 27, 2016

Source:  PLOS One

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell: The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.

Length of publication:   8 pages


The missing evidence: a systematic review of patients’ experiences of adverse events in health care

January 27, 2016

Source:  International Journal for Quality in Healthcare 27/6 pp. 423-41

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Date of publication:  December 2015

Publication type:  Systematic review

In a nutshell:  Reviewers from Australia examined patients’ experiences of adverse events. Eight bibliographic databases were searched from January 2000 to February 2015 and 33 studies were included. The most common issues that patients identified with regard to their healthcare were medication errors and issues with communication and coordination of care. Those with higher income levels and education were more likely to report incidents. People said they felt distressed after adverse events and this was exacerbated by not receiving sufficient information about the causes.  The reviewers recommend that information about patients’ experience of adverse events must be routinely captured and utilized to develop effective, patient-centred and system-wide policies to minimise and manage AEs.

Length of publication:  19 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 alert – Risk of death and serious harm by falling from hoists

November 25, 2015

Source: NHS England

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Date of publication: October 2015

Publication type: Safety alert

In a nutshell:  A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare products Regulatory Agency (MHRA) to highlight the risk of falls from hoists.  A National Reporting and Learning System (NRLS) search identified that there have been 15 incidents in a recent four year period where a person has come to harm through falls from hoists, including one death and three severe injuries.  Providers of NHS funded care have been asked to raise awareness of the risk amongst staff and to ensure they have an action plan underway to reduce the risk of these incidents occurring.

Length of Publication: 1 webpage


Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery

May 28, 2014

Source:  Annals of Surgery 259/4 pp. 630-41

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Date of publication:  April 2014

Publication type:  Journal article

In a nutshell:  The authors completed a systematic review of interventions used to reduce adverse events in surgery. The Newcastle-Ottawa Scale was used to measure the quality of observational studies and RCTs were assessed using the Cochrane Collaboration’s tool for assessing risk of bias. Effective process interventions were submission of outcome data to national audit, use of safety checklists, and adherence to a care pathway. Certain safety technology significantly reduced harm, and team training had a positive effect on patient outcome. The conclusion was that only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement.

Length of Publication:  12 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.