The UK: your partner for global healthcare solutions – Improving the quality and safety of patient care

March 23, 2016

Source:  Department of Health

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Date of publication:  March 2016

Publication type:  Brochure

In a nutshell:  In 2014 the Commonwealth Fund named the NHS as the number one health service for safe care amongst the 11 developed nations studied. The NHS is aiming for a future where avoidable harm is prevented, where 100% of patients achieve the shortest, most uneventful hospital admissions, and where everyone achieves the best possible outcome.

This publication outlines some of the initiatives the UK is currently pursuing, and the organisations which are leading the way in standards of safety. The different sections also provide information on the partners who can best help you achieve your goal of safer, better healthcare.

Length of publication:  15 pages


Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

February 24, 2016

Source:  Applied Ergonomics Jan/52 pp. 185-95

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

Length of publication:  11 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 missing evidence: a systematic review of patients’ experiences of adverse events in health care

January 27, 2016

Source:  International Journal for Quality in Healthcare 27/6 pp. 423-41

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Date of publication:  December 2015

Publication type:  Systematic review

In a nutshell:  Reviewers from Australia examined patients’ experiences of adverse events. Eight bibliographic databases were searched from January 2000 to February 2015 and 33 studies were included. The most common issues that patients identified with regard to their healthcare were medication errors and issues with communication and coordination of care. Those with higher income levels and education were more likely to report incidents. People said they felt distressed after adverse events and this was exacerbated by not receiving sufficient information about the causes.  The reviewers recommend that information about patients’ experience of adverse events must be routinely captured and utilized to develop effective, patient-centred and system-wide policies to minimise and manage AEs.

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


Prevention and control of healthcare-associated infections overview

October 28, 2015

Source:  NICE

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Date of publicationAugust 2015

Publication type:  NICE Pathway

In a nutshell:  The NICE Pathway on the Prevention and control of healthcare-associated infections overview was updated on 17 August 2015 to include the NICE pathway on antimicrobial stewardship.

Length of Publication:  7 pages


Patient safety: threats and solutions

September 25, 2013

Source:  Nursing Standard vol/iss 27/44 pp. 48-55

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Date of publication:  July 2013

Publication type:  Journal article

In a nutshell:  The issues surrounding patient safety are explored in this article, including the language associated with harm and error. The authors discuss the types of patient safety incidents that can occur and they provide insights into why these incidents can occur and explain some of the underlying factors. Preventive strategies and the role of patients and family members in enhancing safety are discussed.

Length of Publication:  8 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.


Medication discrepancies at transitions in pediatrics: a review of the literature

August 29, 2013

Source:  Pediatric Drugs vol/iss 15/3, pp. 203-215

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Date of publication:  June 2013

Publication type:  Journal article

In a nutshell:  Many countries, including the UK, have incorporated medication reconciliation as an important theme for national patient safety initiatives and objectives. The pediatric population are excluded from UK national guidance. This review aimed to discover the occurrence of medication discrepancies in the pediatric population. Small scale studies show that medication discrepancies occur at all transitions of care in children. To investigate and establish how implementing medication reconciliation can reduce discrepancies and prevent potential harm to patients, further research is needed.

Length of Publication:  13 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.


Retained surgical sponges, needles and instruments

May 29, 2013

Source:  Ann R Coll Surg Engl. Vol/iss 95/2 pp. 87-92

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Date of publication:  March 2013

Publication type:  Journal article

In a nutshell:  Retained sponges and instruments (RSI) due to surgery are a recognised medical ‘never event’. The aim of this review was to reveal the extent of the problem of RSI and to detect preventative strategies. Vigilance among operating theatre personnel is paramount if RSI is to be prevented.

Length of Publication:  6 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.