Simulation-based training: the missing link to lastingly improved safety and health?

March 23, 2016

Source: Postgraduate Medical Journal [Epub ahead of print]

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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


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


Improving diagnosis in health care: the next imperative for patient safety

January 27, 2016

Source:  The New England Journal of Medicine 373/26 pp.2493-2495

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell:  This is a commentary of the U.S. report Improving Diagnosis in Health Care that acknowledges the need to address diagnostic error as an urgent patient safety issue.  Summarising the goals from the report, this commentary details how the recommendations can lead to enhanced diagnostic safety and reduced patient harm. The authors also acknowledge potential challenges to implementing the systems and process changes described.

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


Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives

December 23, 2015

Source:  American Journal of Medical Quality 30/6 pp. 550-8

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Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  Although medical error reporting has been studied, under-reporting remains pervasive. The study aims were to identify the organisational factors with the greatest perceived effect on error reporting and to determine whether associations differ for management and clinical staff.

Error feedback was perceived as the most significant predictor, while organisational learning was another significant factor. It also was found that although management support for patient safety was significantly related to error reporting among clinical staff, this association was not significant among management. This difference is relevant because managers may not be aware that their failure to demonstrate support for safety leads to underreporting by frontline clinical staff. Findings from this study can inform hospitals’ efforts to increase error reporting.

Length of publication:  9 pages


Predictors of Patients’ Intentions to Participate in Incident Reporting and Medication Safety

March 26, 2014

Source:  Journal of Patient Safety 2014 Feb 11. [Epub ahead of print]

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Date of publication:  February 2014

Publication type:  Journal article

In a nutshell:  Researchers examined aspects that may influence a patient’s willingness to report a safety error to a national reporting system and to bring their medicines into hospital to allow checking. Beliefs about control were the strongest predictors of patients’ intentions. Their expectations about what is ‘normal’ behaviour influence the extent to which they may participate in patient safety initiatives. The researchers concluded that initiatives to improve patient involvement in safety should consider the extent to which people feel in control and capable of performing the behaviour.

Length of Publication:  Unknown

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.


Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

December 18, 2013

Source:  Drug Safety vol/iss 36/11 pp. 1045-1067

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Date of publication:  November 2013

Publication type:  Journal article

In a nutshell:  The causes of medication administration errors in hospital were examined in this article. Medication lapses were the most commonly reported medication administration errors, followed by mistakes-based on inaccurate knowledge or deliberate violations. Factors potentially leading to medication administration errors included inadequate written communication, problems with medicines supply and storage such as pharmacy dispensing errors and ward stock management, perceived high workload, problems with access to or functioning of ward equipment, patient availability or acuity, fatigue or stress amongst professionals and distractions during drug administration. Medication administration errors are influenced by multiple systems factors so managers and clinicians need to take a system-wide approach to minimise errors.

Length of Publication:  23 pages


New milestone reached in NHS patient safety

December 18, 2013

Source:  NHS England

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Date of publication:  November 2013

Publication type:  News item

In a nutshell:  In this blog post, NHS England’s National Director for Patient Safety, Mike Durkin, discusses the tenth anniversary of the of the first incident reported on the National Reporting and Learning System (NRLS). The NRLS was set up in 2003 to encourage healthcare professionals to talk about errors, learn from them, and to be open and transparent with the patients and families affected by them.

Length of Publication:  1 web page