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

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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.


Keeping patients safe when they transfer between care providers

July 28, 2011

Source: Royal Pharmaceutical Society

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Date of publication: July 2011

Publication type: Guidance

In a nutshell: This guidance looks at the one of the risks to patient care when the patient is transferred between health care providers.   This risk is the miscommunication or unintended change to medications.  The guidance looks at ways to reduce this risk and reduce preventable incidences.

Length of publication: 11 pages

Acknowledgements:  Kings Fund blog


Safe and effective service improvement: delivering the safety

May 28, 2011

Source: Amnis

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Date of publication: May 2011

Publication type: Guidance

In a nutshell: These guidance notes look at implementing Lean as a method of improving patient safety.  This approach looks at reducing costs, time and supplies.  It can also reduce the number of near misses through events that can result in severe death or harm to a patient.

Length of publication: 27 pages