Patient Safety Horizon Scanning Volume 1 Issue 4

November 28, 2010

Situation, Background, Assessment, Recommendation (SBAR)

November 28, 2010

Source;  NHS Institute for Innovation and Improvement 

Follow this link for toolkit resources

Publication Type: Resource

In a nutshell:  SBAR is a toolkit for improving the communication of critical information so that patient safety can be increased by ensuring action is taken quicker. 

Length of publication:  webpage

Acknowledgement:  Trust News, Cumbria Partnership NHS Foundation Trust


Safety when giving insulin in hospital

November 28, 2010

Source:  Nursing Times  Vol 106  Iss 39 p12-13

Follow this link to fulltext

Date of publication:  October 2010

Publication type:  Journal article

In a nutshell:  This article outlines the Rapid Response Report published by the National Patient Safety Agency in June 2010, looking at the risks involved with administering insulin and how these can be minimised.

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.

Acknowledgement:  CINAHL


Disclosure of patient safety incidents : a comprehensive review

November 28, 2010

Source:  International Journal for Quality in Health Care  Volume 22 Issue 5 p371-9

Follow this link for abstract

Date of publication:  October 2010

Publication type:  Review

In a nutshell:  When adverse events occur one of the most challenging and difficult issues are communicating these to patients and families.  This review looks at this area, and the gap between ideal disclosure and the reality.  Perspectives of care team and patients are included along with suggestions on how to improve communication.

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.

Achnowledgement:  MEDLINE


‘Never events’ reported to patient safety agency exceed 100 in one year

November 28, 2010

Source: Nursing Times Vol 106 Iss 40

Follow this link for fulltext

Date of publication: October 2010

Publication type: Journal Article

In a nutshell: This article looks at the number of ‘never events’ reported to the National Patient Safety Agency, including the 14 new events which willl be added to the existing list of 8.  These include serious disability or death from entrapment in bedrails and serious illness or dealth from insulin overdoses.

Length of publication: 1 webpage

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.

Acknowledgement: CINAHL


Signals: emerging issues from national review of serious patient safety incidents

November 28, 2010

Source:  National Reporting and Learning Service, NPSA

Follow this link for report

Date of publication:  October 2010

Publicaton type:  Report

In a nutshell:  Key risks have been identified from a review by the Patient Safety division of the NPSA into serious incidents which have been reported to the NHS.  These issues are in the form of Signals.  10 new ones have been published including ‘Wrong site nerve block’; ‘Non-invasive ventilation’ and ‘Overdose of intravenous paracetamol in infants and children’.

Length of publication:  Webpage

Acknowledgements:  National Patient Safety Agency


NHS trusts put patients’ lives at risk by ignoring safety guidelines.

November 28, 2010

Source:  British Journal of Nursing Vol 19 Iss 17 p1124-1125

Follow this link for abstract

Date of publication:  September 2010

Publication type:  Journal Article

In a nutshell:  This article looks at the recent Action Against Medical Accidents (AvMA) report and discusses the role of patient safety alerts in the NHS, and the widespread failure of trusts to follow up on these and ensure compliance.

Length of publication:  1 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.

Acknowledgement:  CINAHL