Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system

February 24, 2016

Source:  Journal of Patient Safety

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study’s objective was to document such an association across an entire hospital system and across multiple harm types.

Length of publication:  Unspecified

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


Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data

January 27, 2016

Source:  PLOS One

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell: The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.

Length of publication:   8 pages


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


Darzi: The NHS’s approach to patient harm is simplistic and myopic

July 29, 2015

Source:  Health Service Journal, 10 July, 2015

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Date of publicationJuly 2015

Publication type:  News item

In a nutshell: In this comment piece from the HSJ, Lord Darzi, a surgeon and director of the Institute of Global Health Innovation at Imperial College London, argues that changes are needed across cultural, technological and procedural boundaries so as to reduce patient harm. He also says that it is time to learn from other health systems.

Length of Publication:  1 web page



Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients

June 24, 2015

Source:  Annals of Surgery 261/5 pp. 831-8

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Date of publicationMay 2015

Publication type:  Journal article

In a nutshell: This review aims to systematically risk assess and analyse the escalation of care process in surgery to identify problems and provide recommendations for intervention. It discusses Healthcare-Failure-Mode-Effects-Analysis (HFMEA), a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. Failures in the escalation process amenable to intervention were systematically identified in this review. The authors say that the mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

Length of Publication:  8 pages


Clinical safety of England’s national programme for IT: A retrospective analysis of all reported safety events 2005 to 2011

March 25, 2015

Source:  International Journal of Medical Informatics 84/3 pp. 198-206

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Date of publication:  March 2015

Publication type:  Journal article

In a nutshell:  This study aimed to analyse patient safety events associated with England’s national programme for IT (NPfIT). A retrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. The authors conclude that events associated with NPfIT reinforce that the use of IT does create hazardous circumstances and can lead to patient harm or death. Large-scale patient safety events have the potential to affect many patients and clinicians. Addressing these events should be a priority for all major IT implementations.

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


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.

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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


Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery

May 28, 2014

Source:  Annals of Surgery 259/4 pp. 630-41

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Date of publication:  April 2014

Publication type:  Journal article

In a nutshell:  The authors completed a systematic review of interventions used to reduce adverse events in surgery. The Newcastle-Ottawa Scale was used to measure the quality of observational studies and RCTs were assessed using the Cochrane Collaboration’s tool for assessing risk of bias. Effective process interventions were submission of outcome data to national audit, use of safety checklists, and adherence to a care pathway. Certain safety technology significantly reduced harm, and team training had a positive effect on patient outcome. The conclusion was that only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement.

Length of Publication:  12 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.


Reducing harm to patients

April 30, 2014

Source:  The Health Foundation

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Date of publication:  March 2014

Publication type:  Report

In a nutshell: This Health Foundation briefing follows a March 2014 speech by the Secretary of State for Health at Virginia Mason Medical Center in Seattle. Jeremy Hunt MP set out a new ambition to reduce avoidable harm to patients in the NHS during his speech. In recent years, the Virginia Mason Centre has had considerable success in delivering safe care and financial sustainability. This briefing outlines the factors that have contributed to their success, and how a similar approach has been used in the UK. It aims to help those working to improve patient safety in the NHS. The Health Foundation set out five questions that organisations should ask themselves to help make the ambition to reduce avoidable harm a reality.

Length of Publication:  1 web page


Patient safety alert to improve reporting and learning of medication and medical devices incidents

April 30, 2014

Source:  NHS England

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Date of publication:  March 2014

Publication type:  News item

In a nutshell:  Two patient safety alerts have been issued by NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) to help healthcare providers increase incident reporting for medication errors and medical devices. The alerts will improve data report quality and will see the establishment of national networks to maximise learning and provide guidance on minimising harm in relation to these types of incidents. The alerts call on large healthcare provider organisations across a range of healthcare sectors and healthcare commissioners to identify named leaders in both medication and medical device safety roles. The leaders will be supported by two new national networks for medication and medical device safety.

Length of Publication:  1 web page


ESR launches dose reduction campaign

November 27, 2013

Source:  EHealth Insider 23 October 2013

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Date of publication:  October 2013

Publication type:  News item

In a nutshell:  Plans to reduce unsuitable exposure to radiation, including the greater use of computerised dose monitoring and dose repositories have been defined by the European Society of Radiology. The Insights into Imaging website contains a statement that explains the plan of action for improving protection for both patients and staff against excessive doses of radiation. It wants to see what it describes as a GPS approach to the problem; with GPS denoting Globalisation, Personalisation and Safety.

Length of Publication:  1 web page