Errors in the management of cardiac arrests: An observational study of patient safety incidents in England

January 28, 2015

Source:  Resuscitation 85/12 pp.1759–1763

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Date of publication:  December 2014

Publication type:  Journal article

In a nutshell: This study aimed to gain a better understanding of the types of error that occur during the management of cardiac arrests that lead to a death. The reviewers identified a main shortfall in the management of each cardiac arrest and this resulted in 12 different factors being documented. These were then grouped into four themes: miscommunication involving crash number, shortfalls in staff attending the arrest, equipment deficits, and poor application of knowledge and skills. No firm conclusion could be drawn about how many deaths would have been averted if the emergency had been managed to a high standard.

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


Mentorship for newly appointed physicians: a strategy for enhancing patient safety?

November 26, 2014

Source:  Journal of Patient Safety 10/3 pp. 59-67.

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell:  Health-care services are applying mentorship in their settings, learning from business and industry where it is a popular innovation. This article looks at the concept of mentorship for newly appointed physicians in their first substantive senior post and in particular at its deployment to enhance patient safety. Semi-structured interviews were conducted with Medical Directors, Deputy Medical Directors and Clinical Directors from 9 acute NHS Trusts in the Yorkshire and Humber region in the north of England. A number of beneficial outcomes were found, including greater personal and professional support, organisational commitment, and general well-being. Providing newly appointed senior physicians with support through mentorship was considered to enhance the safety of patient care.

Length of Publication:  9 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


New patient safety Collaboratives launched

October 29, 2014

Source:  National Health Executive

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Date of publication:  October 2014

Publication type:  News item

In a nutshell: A new national programme to improve patient safety will see the establishment of 15 Patient Safety Collaboratives – each led by an Academic Health Science Network (AHSN). Each Collaborative will be funded for the next five years by NHS England. The Collaboratives will support individuals, teams and organisations to build skills and knowledge about patient safety and quality improvement. The Collaboratives are aligned with, and support, the ‘Sign up to Safety’ campaign to make the NHS the safest healthcare system in the world.

Length of Publication:  1 web page


NHS England publishes Never Events Policy Framework Review consultation online

October 29, 2014

Source:  NHS England

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Date of publication:  October 2014

Publication type:  News item

In a nutshell: NHS England has published the Never Events Policy Framework Review consultation. The consultation will help to show what needs to be done, and by whom, to prevent never events. Part of the review will also consider financial penalties for never events, and how this might be included in the NHS Standard Contract for 2015/16. The review is focusing on five key issues: the purpose, definition, list of, management, and application of learning from never events. The overall aim of the review is to keep patient safety as a focus for action, and to foster a culture which aims to share learning and improve, rather than to blame and penalise.

Length of Publication:  1 web page


East Cheshire implements iPad safety system

October 1, 2014

Source:  Health Service Journal 1, September 2014

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Date of publication:  September 2014

Publication type:  News item

In a nutshell:  An iPad based system funded by the Nursing Technology Fund is being used by nurses at East Cheshire Trust to monitor patient safety. Macclesfield Hospital has begun recording clinical data electronically on handheld devices at the patients’ bedside, replacing the standard practice of recording observations on a paper chart at the end of the bed. Nurses input vital signs and other clinical observations into the devices, and the “VitalPAC” system automatically calculates a risk score which will alert staff immediately to any deterioration and provide advice on an appropriate response. The system is to be rolled out to all inpatient wards at Macclesfield Hospital.

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


Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training

October 1, 2014

Source:  BMJ Quality & Safety Aug 18. [Epub ahead of print]

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Date of publication:  August 2014

Publication type:  Journal article

In a nutshell:  This study aimed to measure the impact of patient narratives used to train junior doctors in patient safety. A trial was conducted in the North Yorkshire East Coast Foundation School (NYECFS). The intervention consisted of 1-h-long patient narratives followed by discussion. The Attitude to Patient Safety Questionnaire (APSQ) and the Positive and Negative Affect Schedule (PANAS) were used to measure the impact of the intervention. The authors state that involving patients with experiences of safety incidents in training has an ideological appeal and seems an obvious choice in designing safety interventions, but that they were unable to demonstrate the effectiveness of the intervention in changing general attitudes to safety compared to control.

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


An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

August 27, 2014

Source:  Anaesthesia 69/7 pp. 735-45

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Date of publication:  July 2014

Publication type:  Journal article

In a nutshell:  One of the key tools promoted for improving patient safety in healthcare is incident reporting. The authors of this study analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units in the North West of England every year between 2009 and 2012. 452 of the incidents led to harm to patients. The most commonly reported drugs were noradrenaline, heparins, morphine and insulin. The administration of drugs was the stage where incidents were most commonly reported. This was also the stage most likely to harm patients. The authors conclude that quality improvement initiatives could improve medication safety in the units studied.

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