Patient Safety Horizon Scanning Volume 1 Issue 5

December 22, 2010

A model for developing high-reliability teams.

December 22, 2010

Source: Anaesthesia  Vol 65 Iss 11 p1106-1113

Follow this link for astract

Date of publication: November 2010

Publication type: Journal article

In a nutshell: This article looks at the instances where misuse of an anaesthetic has casued adverse effects.  It also looks at providing recommendations on how to improve this.  The incidences were taken from the National Reporting and Learning System in England and Wales between 2006 and 2008.

Length of publication: 7 pages

Some important information:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Acknowledgement: EMBASE


Stockport transforms theatre efficiency through innovation

December 22, 2010

Source: HealthExecTV

Click here to view video

Date of publication: November 2010

Publication type: Interview

In a nutshell: This interview highlights improvements which have been made in the surgical department at Stockport NHS Foundation Trust.  These improvements have lead to cost-savings, and reduced operating time set up by 15 minutes.

Length of publication: 15 minutes

Some important notes: You will need to register to view the video.  Registration is free.


Prevalence, reporting and pressure ulcer management

December 22, 2010

Source: Healthcare Quality Improvement Partnership – HQIP

Follow this link for newsitem

Date of publication: 3 October 2010

Publication type: Report

In a nutshell: This item looks at how, through incident report monitoring and clinical audit against NICE guidelines, one Trust successfully dealt with the management of pressure ulcers, realising both improved patient care and quality .

Length of publication: 1 page


The QIPP Safe Care Work Stream: Safety Express

December 22, 2010

Source: http://www.advancingqualityalliance.nhs.uk/

Click here to access article

Date of publication: November 2010

Publication type: Article

In a nutshell: This article from AQuA looks at the national improvement programme starting in January 2011, focussing on supporting improvements to deliver ‘no harm care’ to increase  both efficiency and cost savings in four areas:  serious harm from falls, urinary tract infections from catheters, pressure ulcers and Venous Thrombembolism (VTE).

Length of publication: 3 pages

Acknowledgement: Department of Health Workstream: Safe Care


Death rates better – but some Trusts still too high

December 22, 2010

Source: BBC News

Follow this link for news item

Date of publication: 28 November 2010

Publication type: News item

In a nutshell: This article looks at the results of a survey into the patient care in England, especially the death rates.  It highlights the fact that Trusts which need to improve in this area to ensure there is equality of care especially for those less well off.  The article also provides comments from hospital staff regarding the usefulness of these results.

Length of publication: 1 web page

Acknowledgement: Dr Foster’s Hospital guide 2010


Clinicans warned of the dangers of loading doses of drugs

December 22, 2010

Source: National Patient Safety Agency

Follow this link for news item

Date of publication: 25 November 2010

Publication type: News Item

In a nutshell:  The NPSA has issued a new Rapid Response Report (RRR) in a bid to reduce the possibility of harming or causing death through overloading syringes with medicine.   

Length of publication: 1 webpage