Our approach to changing the culture of caring for the acutely unwell patient at a large UK teaching hospital: A service improvement focus on Early Warning Scoring tools

May 22, 2015

Source: Intensive & Critical Care Nursing 31/2 pp. 106-15

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Date of publication:  April 2015

Publication type:  Journal article

In a nutshell:  Early Warning Scoring tools have been in place in Nottingham University Hospitals NHS Trust for over five years but compliance has been low. A service improvement project commenced across all admission wards in 2013. Prior to the project, only one out of five clinical care targets set were achieved. An established framework for service improvement was used to guide delivery. Since introduction of the service improvement team, consistent signs of improvement have been visible across the admission areas in four out of five of the clinical care targets. The first 12 months of the project has seen benefits in patient care and staff experience.

Length of Publication:  10 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


Serious Incident Framework

April 29, 2015

Source:  NHS England

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Date of publicationMarch 2015

Publication type:  News item

In a nutshell: The revised Serious Incident Framework from NHS England provides renewed guidance to help organisations respond to serious incidents appropriately.

Length of Publication:  1 web page


Revised Never Events Policy and Framework

April 29, 2015

Source:  NHS England

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Date of publicationMarch 2015

Publication type:  News item

In a nutshell: The revised Never Events Policy and Framework from NHS England, includes changes to the definition of a never event and adjustments to the never events list.

Length of Publication:  1 web page


Developing a patient measure of safety (PMOS)

August 29, 2013

Source:  BMJ Quality and Safety vol./iss 22/7 pp. 554-562

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Date of publication:  July 2013

Publication type:  Journal article

In a nutshell:  In high-risk industries, tools that can identify factors that contribute to accidents have been developed. Patients provide feedback on their experience of care in hospitals, but there are no existing measures asking patients to comment on issues that can lead to patient safety incidents. This study aimed to define  contributory factors from the Yorkshire Contributory Factors Framework (YCFF) that patients are able to identify in a hospital setting and to use this information to develop a patient measure of safety (PMOS). The draft PMOS worked well and showed that patients are able to identify factors which contribute to the safety of their 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.


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


Updated never events policy framework and data published

December 3, 2012

Source: Department of Health

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Date of publication: October 2012

Publication type: Policy document

In a nutshell: To address areas of uncertainty and provide greater clarity about never events and the recommended response to them following feedback from stakeholders, the never events policy framework has been reviewed and updated. It is a useful reference for clinicians, other staff and patients. The update contains data on the number and types of never event reported in the last two years.

Length of publication: 1 web page


Skills in improving quality, safety, patient experience and value with peers within primary care

July 30, 2012

Source: NHS Commissioning Board

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Date of publication: June 2012

Publication type: Toolkit

In a nutshell:  A list of products, including frameworks and toolkits to help senior teams, individual leaders and whole CCGs to improve patient experience.