Patient safety and the problem of many hands

March 23, 2016

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

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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

NHS can be ‘world leader’ on patient safety, say healthcare leaders

July 29, 2015

Source:  Health Service Journal, 14 July, 2015

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Date of publicationJuly 2015

Publication type:  News item/report

In a nutshell: A new report, The Case for Patient Safety: Financially, Professionally and Ethically, has been published by the Health Service Journal (HSJ). It features contributions from NHS England chief executive Simon Stevens and medical director Sir Bruce Keogh, and CQC chief inspector of hospitals Sir Mike Richards. It also includes work from Martin Bromiley, chair of the Clinical Human Factors Group and James Titcombe, national adviser on patient safety to the CQC.

Length of Publication:  1 web page

CQC could become enforcer of ‘zero harm’ rules

February 20, 2015

Source:  Health Service Journal 21 January 2015

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Date of publication:  January 2015

Publication type:  News item

In a nutshell:  A proposed new law on patient safety would open the door to tougher regulation of health and care providers by the Care Quality Commission.

Length of Publication:  1 web page

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

BMJ Quality & Safety: a collection of key articles

April 30, 2014

Source:  The Health Foundation

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Date of publication:  April 2014

Publication type:  News item

In a nutshell:  This page links to a special collection of the best articles published in BMJ Quality & Safety in 2013. The BMJ Quality and Safety journal is co-owned by the Health Foundation and the BMJ Group. The articles featured in this collection include: identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia; the global burden of unsafe medical care: analytic modelling of observational studies; systematic review of the application of the plan–do–study–act method to improve quality in healthcare; ‘care left undone’ during nursing shifts: associations with workload and perceived quality of care; culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.

Length of Publication:  1 web page

NHS England announces a further £150m to improve patient safety and care

January 29, 2014

Source:  NHS England

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Date of publication:  December 2013

Publication type:  News item

In a nutshell:  To help improve patient safety and help to make the NHS the safest healthcare system in the world, hospitals are to get a further £150 million boost. NHS England has worked with Monitor and they expect the money to be used to both improve safety and to ensure that patients are treated with care and compassion, such as employing extra nurses.  The money will come from Clinical Commissioning Groups usual financial settlement.

Length of Publication:  1 web page

Closing the gate before the horse bolts: a new approach to patient safety

June 24, 2013

Source:  The Health Foundation

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Date of publication:  May 2013

Publication type:  Blog post

In a nutshell:  A blog post by Elaine Maxwell that considers whether care is any safer today than it was in 2001 when the National Patient Safety Agency was established.

Length of Publication:  1 web page

The measurement and monitoring of safety

April 26, 2013

Source:  The Health Foundation

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Date of publication:  April 2013

Publication type:  Report

In a nutshell:  There is now a great awareness of the problem of medical harm, and significant efforts have been made to improve the safety of healthcare. The authors have synthesised available evidence and have proposed a single framework that brings together a number of conceptual and technical facets of safety. This framework highlights five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a widespread and rounded picture of an organisation’s safety. The dimensions are past harm, reliability, sensitivity to operations, anticipation and preparedness, and integration and learning.

Length of Publication:  92 pages