Patient Safety Horizon Scanning Volume 2 Issue 2

February 28, 2011

The quest to eliminate intrathecal vincristine errors: a 40-year journey

February 28, 2011

Source: Postgraduate Medical Journal

 Follow this link for abstract

Date of publication: January 2011

Publication type: Article

In a nutshell: This article looks at avoidable errors in the application of intrathecal vincristine.  It suggests that there are 5 major areas why these incidents continue to occur, where lessons need to be learned, and applied across the board in other areas of healthcare.  These are: 1. Failure to learn from adverse events; 2. Failure of international translation; 3. Failure to achieve compliance with safety guidelines; 4. Failure of investigations and enquiries; 5. Failure of solutions.

Length of publication: 3 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.


The role of theory in research to develop and evaluate the implementation of patient safety practices

February 28, 2011

Source: BMJ Quality & Safety Volume 20

Follow this link for abstract

Date of publication: 11 February 2011

Publication type: Article

In a nutshell: This article suggests that theory should be added to interventions as they can provide a way of predicting or mitigating the effects of Patient Safety Practices (PSPs).  It further suggests that adding the theoretical basis to the PSPs will enable learning in different contexts.

Length of publication: 6 pages

Some important information:  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.  Follow this link to find your local NHS Library.


The NHS needs to change faster – here’s how to do it.

February 28, 2011

Source: Health Serivce Journal

Follow this link for  abstract

Date of publication: 9 December 2010

Publication type: Article

In a nutshell: An initiative has been recently launched with the aim: ‘keep patients safe and free from harm’.  They hope to accomplish this in the areas of pressure ulcers, falls and nutrition.  The initiative is called ‘Rapid Spread’ and the aim is to have this initiative introduced to all wards and clinical areas at the same time ensuring that they tackle the ‘same work in the same way at the same time’.

Length of publication: supplement

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.


Improving patient safety through education

February 28, 2011

Source: BMJ Volume 342

Follow this link for abstract

Date of publication: 9 February 2011

Publication type: Article

In a nutshell: This article looks at the important of including human factors in undergraduate and postrgraduate education.  It also seeks to underline the continued importance of investment into education and training in a climate where cost savings are a priority. 

Length of publication: 1 page

Some important information:  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.  Follow this link to find your local NHS Library.


A wake up call – lessons from the first major improvement programme

February 28, 2011

Source: The Health Foundation

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Date of publication: 4 February 2011

Publication type: News item

In a nutshell: The Health Foundation looks at their ‘Safer Patient Initiative’,  evaluating the lessons learned from it.  It also looks at the success achieved on ward level, and raising awareness of these issues across the UK.  However, more lessons are to be learned if this is to have an impact at organisation level, and this article highlights some of the ways to achieve this.

Length of publication: 1 webpage


How to guide to venous thromboembolism risk assessment

February 28, 2011

Source: National Reporting and Learning Agency

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Date of publication: 2 February 2011

Publication type: Guidance

In a nutshell:  This is a ‘How to’ guide to support NHS organisations in carrying out venous thromboembolism risk assessments on newly admitted patients.  It builds on existing resources and supports the implementation of National Institute for Health and Clinical Excellence (NICE) Quality Standards Programme, CQUIN requirements and NICE Guideline 92.

Length of publication:1 web page

Acknowledgement: National Patient Safety Agency