Learning from preventable deaths: exploring case record reviewers’ narratives using change analysis

November 26, 2014

Source: Journal of the Royal Society of Medicine 107/9 pp. 365-75.

Follow this link for item

Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: The authors set out to determine if applying change analysis to the narrative reports made by reviewers of hospital deaths in acute NHS Trusts in 2009 increases the utility of this information in the systematic analysis of patient harm. The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. The method was straightforward to apply to multiple records and achieved good inter-rater reliability. Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach.

Length of Publication:  11 pages


Safe and effective service improvement: delivering the safety

May 28, 2011

Source: Amnis

Follow this link for fulltext

Date of publication: May 2011

Publication type: Guidance

In a nutshell: These guidance notes look at implementing Lean as a method of improving patient safety.  This approach looks at reducing costs, time and supplies.  It can also reduce the number of near misses through events that can result in severe death or harm to a patient.

Length of publication: 27 pages


Putting patient safety back at the heart of the NHS

April 4, 2011

Source: Department of Health

Follow this link for fulltext

Date of publication: February 2011 

Publication type: News Item

In a nutshell: The Department of Health has increased the list of ‘Never Events’ from 8 to 25.  The list now includes severe scalding; severe harm/death due to misidentifying patients and severe harm/death due to transferring the wrong blood type.  The Never Events List for 2011/2012 can be viewed by clicking here.

Length of publication: 1 web page


Death rates better – but some Trusts still too high

December 22, 2010

Source: BBC News

Follow this link for news item

Date of publication: 28 November 2010

Publication type: News item

In a nutshell: This article looks at the results of a survey into the patient care in England, especially the death rates.  It highlights the fact that Trusts which need to improve in this area to ensure there is equality of care especially for those less well off.  The article also provides comments from hospital staff regarding the usefulness of these results.

Length of publication: 1 web page

Acknowledgement: Dr Foster’s Hospital guide 2010