Improving health care quality and safety: the role of collective learning

December 23, 2015

SourceDove Press 2015/7 pp. 91—107

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Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. The review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes.

Length of publication:   17 pages


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


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


Codifying knowledge to improve patient safety: A qualitative study of practice-based interventions

July 30, 2014

Source:  Social Science and Medicine 113 pp. 169-176

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Date of publication:  June 2014

Publication type:  Journal article

In a nutshell:  Knowledge codification is the conversion of implicit or tacit knowledge to explicit knowledge so that it is effective for making change. Patient safety interventions were implemented by two NHS hospitals through the codification of knowledge. One hospital introduced a structured mortality review process and another hospital used a medication safety scorecard on a general medicine and elderly care ward. Codification helped staff learn about patient safety by structuring the sharing of tacit knowledge. Good organisational governance and support is needed to help translate knowledge across levels.

Length of Publication:  8 pages


Six-monthly patient safety incident data shows incident reporting in the NHS continues to improve

May 28, 2014

Source:  NHS England

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Date of publication:  May 2014

Publication type:  News item

In a nutshell: Six-monthly data on patient safety incidents reported to the National Reporting and Learning System (NRLS) has been published from between 1 April and 30 September 2013. According to the data, the NHS is continuing to get better at recognising and reporting patient safety incidents. The new data shows an increase of 8.9% in the number of incidents reported compared to the same period in the previous year, as the NHS continues to be more open and transparent around patient safety incident reporting. It will enable NHS England to identify and take action to prevent emerging patterns of incidents on a national level via patient safety alerts. Locally incident reporting enables clinicians to learn from their own and others’ services about why patient safety incidents happen and they can then act to prevent their own patients being placed at similar risks.

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


Experience-based co-design toolkit

December 18, 2013

Source:  The King’s Fund

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Date of publication:  November 2013

Publication type:  Toolkit

In a nutshell:  A new version of the experience-based co-design toolkit – a powerful and effective way to help service providers run and assess their own patient-centred care projects – has been launched. The toolkit incorporates learning and feedback from staff and patients involved in more than 60 EBCD projects, including an important adaptation, the accelerated form of EBCD.

Length of Publication:  1 web page