The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study

October 29, 2014

Source:  BMC Health Services Research 14 pp. 432

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: There is evidence that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to the reasonable adjustments that they need not being implemented. This article aimed to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities. It describes the patient safety issues that patients with intellectual disabilities in NHS acute hospitals encounter and investigates underlying contributory factors. The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents.

Length of Publication:  1 web page


Measuring and monitoring safety: an acute care perspective

November 27, 2013

Source:  The Health Foundation

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Date of publication:  October 2013

Publication type:  Report

In a nutshell:  A Thought paper from The Health Foundation in which Dr Carol Peden offers opinions on the measurement and monitoring of safety from the viewpoint of a clinician at a busy district general hospital. Dr Peden looks at where patient safety work is directed within her hospital, the areas of safety that have challenged her, and explains what she has learnt whilst trying to improve safety. This is one of five thought papers on patient safety recently published on the Health Foundation website.

Length of Publication:  12 pages


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


Safety culture: What is it and how do we monitor and measure it?

April 26, 2013

Source:  The Health Foundation

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Date of publication:  March 2013

Publication type:  Report

In a nutshell:  A report from a roundtable event hosted by the Health Foundation in February to discuss what is understood as ‘safety culture’, why it is significant and how it can be measured and monitored. The event was held as part of the Health Foundation’s work to lead a change in thinking about patient safety. There is a summary of the discussion and the themes that should be explored further.

Length of Publication:  6 pages


Assessment and accreditation system improves patient safety

January 30, 2013

Source: Nurs Manag (Harrow)  Vol/iss  19/7  pp29-33.

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Date of publication:  November 2012

Publication type: Journal article

In a nutshell: The Nursing Assessment and Accreditation System was introduced by Salford Royal NHS Foundation Trust in 2008. It is a ward-based performance assessment framework, designed to foster a culture of safety by helping nurses monitor the quality of care. Based on the trust’s “Safe, Clean and Personal Every time” approach to service provision, it is intended to support attention to safety and quality improvement, to ensure patients are placed at the centre of care services.

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.


Perioperative care in practice: A case study

April 4, 2011

Source: The Health Foundation

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Date of publication: March 2011

Publication type: Case Study

In a nutshell: This case study publishes the results of two hospitals, Causeway Hospital and Wrexham Maelor Hospital, who have implemented the ‘Safer Patient Initiative‘ in an attempt to improve monitoring of perioperiative procedures. 

Length of publication: 6 pages

Acknowledgement: NHS Evidence