International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

March 23, 2016

Source:  BMJ Quality & Safety [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care.  This study used a Delphi approach to determine consensus regarding the ideal role of PSRSs and to devise recommendations for best practice.

The study resulted in reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

Length of publication:  14 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


Improving the safety of vaccine delivery

March 23, 2016

Source:  Human Vaccines & Immunotherapeutics [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Vaccines save millions of lives per annum and are an integral part of community primary care provision worldwide. The World Health Organization has highlighted that the adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst it is known that as many as one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and drug adverse event surveillance systems are proving useful informants for understanding the underlying causes of those errors. The challenge now lies in the identification and implementation of changes to improve vaccine safety at multiple levels: from patient level interventions through to organisational efforts at local, national and international levels. The authors consider the potential benefits for maximising learning from patient safety incident reports to improve the quality and safety of care delivery.

Length of publication:  Unspecified

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


Accounting for actions and omissions: a discourse analysis of student nurse accounts of responding to instances of poor care

February 24, 2016

Source:  Journal of Advanced Nursing [epub ahead of print]

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Date of publication:  January 2016

Publication type:  Journal article

In a nutshell:  Failure to report cases of poor care may have serious consequences for patient safety. The aim of this study was to explore how nursing students account for decisions to report or not report poor care witnessed on placement and to examine the implications of findings for educators.

The findings were that participants took care to present themselves in a positive light regardless of whether or not they had reported an episode of concern. Those who had reported tended to attribute their actions to internal factors such as moral strength and a commitment to a professional code. Those who had not or would not report concerns provided accounts which referred to external influences that prevented them from doing so or made reporting pointless.

This study provides information about how students account for their actions and omissions in relation to the reporting of poor care. Findings suggest ways educators might increase reporting of concerns.

Length of publication:  Unspecified


Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data

January 27, 2016

Source:  PLOS One

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell: The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.

Length of publication:   8 pages


How has the NHS improved patient safety?

December 22, 2014

Source:  The Guardian Healthcare Network

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Date of publication:  November 2014

Publication type:  News item

In a nutshell: John Illingworth, policy manager at the Health Foundation, looks at the impact that the Berwick report has had on patient safety in the NHS. The headline results of a survey sent out to every NHS Provider in England are set out in an infographic. John Illingworth concludes that the survey results show positive signs about how organisations at a local level are pursuing safer care, and cause for thought at a national level as to how further progress can be supported.

Length of Publication:  1 web page


Berwick review into patient safety

August 29, 2013

Source:  Department of Health

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Date of publication:  August 2013

Publication type:  Report

In a nutshell:  The main problems affecting patient safety in the NHS are highlighted in this report, by Professor Don Berwick, an international expert in patient safety, and there are recommendations made to address them. The report states that the health system must recognise the need for system wide change and insist on the primacy of working with patients and carers to achieve health care goals. It also says that the NHS needs to ensure that the responsibility for functions related to safety and improvement are established clearly and simply.

Length of Publication:  1 web page


NHS England to review low number of GP patient safety reports

July 31, 2013

Source:  Pulse 9 July 2013

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Date of publication:   July 2013

Publication type:  News item

In a nutshell:  The low numbers of patient safety incidents reported by GPs, which make up 0.5% of all incidents reported in the NHS, is to be investigated by NHS England, in an attempt to encourage practitioners to report adverse events. The General Practitioners Committee (GPC) has explained that it is likely there will be fewer adverse events in general practice, but it said GPs are less likely to report the adverse events because of a ‘blame culture’. A patient safety expert group for primary care is being set up to look into the low number of reports.

Length of Publication:  1 web page

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.


Latest patient data shows improvement in reporting

April 26, 2013

Source:  NHS England

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Date of publication:  March 2013

Publication type:  Press release

In a nutshell:  NHS England has released the National Reporting and Learning System (NRLS) Organisation Patient Safety Reports. The reports show progress in the reporting of patient safety incidents from April to September 2012.

Length of Publication:  1 web page


Patient safety in vitreoretinal surgery: quality improvements following a patient safety reporting system

April 26, 2013

Source:  Br J Ophthalmol. Vol/iss 97/3 pp. 302-7.

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Date of publication:  March 2013

Publication type:  Journal article

In a nutshell:  Vitreoretinal (VR) surgery is complex and many clinical conditions that VR surgeons manage have a high risk for blindness or severe visual impairment. The authors examined the role of PSI reporting in making VR surgery safer at their institution. VR PSI reporting resulted in a change in clinical practice. Longitudinal analysis suggests an accompanying increase in patient safety.

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.


Review of NHS critical infrastructure risk initiated

December 24, 2012

Source: Department of Health

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Date of publication: December 2012

Publication type: News item

In a nutshell: This letter was sent to NHS organisations who have been invited to participate in the review of the NHS’s recurrent report for of a need for significant investment in maintenance of its facilities. This is intended to eliminate ‘critical risks’ to the safety of patients, visitors and staff; and the resilience of its services.

Length of publication: 1 web page


Can patients report patient safety incidents in a hospital setting?

July 30, 2012

Source:  BMJ Quality & Safety

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Date of publication: May 2012

Publication type:  Journal article

In a nutshell:  This article looks at the current situation of whether patients can report incidents while they are in the hospital, and whether this should be something to build on in the future.

Length of publication:  9 pages

Some important notes:   If an item requires an Athens username and password.  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


Harm from flushing of nasogastric tubes before confirmation of placement

April 30, 2012

Source:  National Reporting and Learning System, NPSA

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Date of publication: March 2012

Publication type:  Reports

In a nutshell: This is one of 7 signals recently published on Medication safety.  It focusses on the importance of insuring that nasogastric tubes are correctly placed.  The report has been published in response to two patient deaths from wrongly sited tubes.

Length of publication:  1 web page