The commission on education and training for patient safety: improving patient safety through education and training

March 23, 2016

Source:  Health Education England

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Date of publication: March 2016

Publication type:  Report

In a nutshell:  Produced by the Commission on Education and Training for Patient Safety and supported by Imperial College the report sets out ambitions, the case for change, what is working well including case studies and where improvements need to be made to make the greatest difference to patient safety both now and in the future. It sets out the future of education and training for patient safety in the NHS over the next ten years, making twelve recommendations to Health Education England and the wider system.

Length of publication:  60 pages


Safety standards for invasive procedures: beware the implementation gap

March 23, 2016

Source:  BMJ 352:i1121

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Nick Sevdalis is professor of implementation science and patient safety at King’s College London.  In this editorial he offers advice regarding the implementation of the recent NHS England guideline National Safety Standards for Invasive Procedures (NatSSIPs).  

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


Researchers’ roles in patient safety improvement

March 23, 2016

Source:  Journal of Patient Safety 12/1 pp. 25–33

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Date of publication: March 2016

Publication type:  Journal article

In a nutshell:  This article explores how researchers can contribute to patient safety improvement with the aim of expanding the instrumental role researchers have often occupied in relation to patient safety improvement.

The conclusions were that when working side by side with “practice,” researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds—as well as other actors involved in patient safety improvement—in structuring their work and collaborating productively.

Length of publication:  9 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 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


Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system

February 24, 2016

Source:  Journal of Patient Safety

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study’s objective was to document such an association across an entire hospital system and across multiple harm types.

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


Improving the governance of patient safety in emergency care: a systematic review of interventions

February 24, 2016

Source:  BMJ Open 6/1

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Date of publication:  January 2016

Publication type:  Systematic review

In a nutshell:  The objective of this study was to systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.

The conclusions were that the characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in emergency medical services organisations and emergency departments. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base.

Length of publication:  1 webpage


Responding to concerns

February 24, 2016

Source:  Health Education England

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Date of publication: January 2016

Publication type:  Video

In a nutshell:  ‘Responding to Concerns’, is a new educational film developed by Health Education England that aims to improve patient safety. Developed with input from patient safety experts, including our raising concerns network, the film aims to equip staff with the knowledge, skills and confidence to adequately and safely respond to patient safety concerns.

Length of publication:  1 webpage


Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population

February 24, 2016

Source:  International Journal for Quality in Healthcare [Epub ahead of print]

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population.

The authors conclude that this study demonstrates that a framework for patient safety can be applied to facilitate the organisation and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardised framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.

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


Aviation and healthcare: a comparative review with implications for patient safety

February 24, 2016

Source:  Journal of the Royal Society of Medicine 0/0 pp. 1-10

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Date of publication:  January 2016

Publication type:  Journal article

In a nutshell:  Safety in aviation has often been compared with safety in healthcare. The UK government recently set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, the authors have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare have been derived and documented.

The authors conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

Length of publication:   10 pages


Patient Safety & Congress Awards 2016

February 24, 2016

Source:  Patient Safety Congress & Awards

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Date of publication: February 2016

Publication type:  Website

In a nutshell:  The Patient Safety Congress 2016, 5 – 6 July, is to be held in Manchester and the theme is inspiring our workforce: finding solutions with staff and patients. The conference will showcase the best work from across the UK, using innovative, proven solutions to tackle everything from large-scale redesign of emergency services to reduce readmissions to new approaches to cost-effective patient-led decision making.

Length of publication:  1 webpage


Patient safety alert – The risk of using different airway humidification devices simultaneously

January 27, 2016

Source:  NHS England

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Date of publication:  December 2015

Publication type:  Safety alert

In a nutshell: A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare Products Regulatory Agency (MHRA) to raise awareness of the risk of having two different types of airway humidification devices simultaneously connected to a patient’s ventilation equipment.

There are two humidifiers in common use: heated [water] humidifiers (HHs), usually located between the ventilator and the breathing system; and heat and moisture exchangers (HMEs), placed at the patient’s end of the breathing system. The inadvertent use of both types of humidifier simultaneously can cause the HME to become saturated with water and could lead to the airway becoming obstructed.

NHS providers are asked to take local action to prevent the risk.

Length of publication:  1 webpage


Evaluating the effectiveness of a peer-led education intervention to improve the patient safety attitudes of junior pharmacy students: a cross-sectional study using a latent growth curve modelling approach

January 27, 2016

Source:  BMJ Open

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell:  Researchers in Australia tested using senior pharmacy trainees as peer educators to improve knowledge about patient safety. Junior trainees were surveyed before, immediately after and one month after taking part in a patient safety education programme. Feedback was compared with those who had not taken part. The programme covered introductory patient safety topics including teamwork, communication skills, systems thinking and open disclosure. Two lectures were provided by a lecturer and a workshop was provided by final-year pharmacy students. Trainees’ safety attitudes improved, particularly with regards to questioning behaviours and open disclosure of incidents.

Length of publication:  1 webpage