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

Source:  Dove 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

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

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

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

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

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

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

Ensuring patient safety blood transfusion

Source:  Nurs Times Vol/iss 109/4 pp. 22-3.

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Date of publication:  January-February 2013

Publication type:  Journal article

In a nutshell:  This paper discusses the fact that blood transfusion is a common procedure, that it carries a degree of risk, and that avoidable mistakes can result in serious or fatal consequences. Adverse events are largely associated with human error so current knowledge and skills of the blood grouping system and compatibility, and the ability to identify, respond to and report reactions, are essential for patient safety. An online Nursing Times Learning unit on safe blood transfusion is being launched soon.

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.

NPSA publishes patient safety incident data update

Source: National electronic Library for Medicines

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Date of publication: 13 September 2012

Publication type: News item

In a nutshell: Data workbooks covering organisation patient safety incident reports data for incidents that occurred between 1 October 2011 and 31 March 2012 and were reported to the National Reporting and Learning System (NRLS) by 31 May 2012 have been issued by the National patient Safety Agency (NPSA). Workbooks covering data by region and data by organisation are available.

Length of publication: 1 web page

Accountability, organisational learning and risks to patient safety in England: Conflict or compromise?

Source: Health, Risk & Society vol. 13 iss 4  pp327-346)

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Date of publication: June 2011

Publication type: journal article

In a nutshell: This article looks at 2 approaches to patient safety within the NHS – promoting accountability & promoting learning lessons from previous mistakes and near-misses.  These approaches can sometimes be conflicting however, the article looks at how these approaches can work together.

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.

Acknowledgements:  CINAHL

Keywords: 

Categories:  Volume 2 Issue 6;

Apprenticeships enhance patient safety and care.

Source:  Nursing Times 2011 Apr 12-18; 107(14):21-2.

Date of publication: April 2011

Publication type: Journal article

In a nutshell: This article provides details of a modern staff apprenticeship programme. It shows how it can act as a recruitment path for health care assistants and so benefit patient safety. The article also describes other staff development approaches to improve safety.

Length of publication: 2 pages

Some important information:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Acknowledgement: NHS Evidence

The role of theory in research to develop and evaluate the implementation of patient safety practices

Source: BMJ Quality & Safety Volume 20

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Date of publication: 11 February 2011

Publication type: Article

In a nutshell: This article suggests that theory should be added to interventions as they can provide a way of predicting or mitigating the effects of Patient Safety Practices (PSPs).  It further suggests that adding the theoretical basis to the PSPs will enable learning in different contexts.

Length of publication: 6 pages

Some important information:  This article is available in full text to all NHS Staff using Athens, for more information about accessing full text fllow this link to find your local NHS Library.  Follow this link to find your local NHS Library.