Patient Safety Horizon Scanning Volume 2 Issue 6

July 28, 2011

Does the implementation of an electronic prescribing system create unintended medication errors

July 28, 2011

Source: BMC Medical Informatics and Decision Making Volume 11, p29

Follow this link for fulltext

Date of publication: May 2011

Publication type: Study

In a nutshell: This study looks at whether there are electronic prescribing systems could have a negative impact on patient care as well as a positive one.  The negative impact is in the area of administration of medicine.  The study was based in an acute hospital in the Midlands in the UK.

Length of publication: 1 web page

Some important notes: Open access article

Acknowledgements:  HMIC


Supporting Quality and Patient Safety in Cancer Clinical Trials.

July 28, 2011

Source: Clinical Journal of Oncology Nursing, vol 15 Iss 3  pp263-265

Follow this link for abstract

Date of publication: June 2011,

Publication type: journal article

In a nutshell:   This article looks at the terminology used by clinicians to describe the severity of the adverse events (AEs).  The terminology comes from the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE).  To support patient safety it is suggested that Oncology Clinical Trial Nurses should develop and understanding of these.

Length of publication: 3 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.

Acknowledgements:   CINAHL


IV therapy in the community

July 28, 2011

Source: Nursing Times, Volume 107, Issue 19, p15-18

Follow this link for abstract

Date of publication: 15 May 2011

Publication type: Journal article

In a nutshell: this article looks at the benefits of increasing community IV therapy services on hospital admissions and early discharge.  These include reduction of the risk of infection, and improved choice, on patient safety.  The article also provides guidance for nurses on setting up such a service.

Length of publication: 3 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: HMIC


Accountability, organisational learning and risks to patient safety in England: Conflict or compromise?

July 28, 2011

Source: Health, Risk & Society vol. 13 iss 4  pp327-346)

Follow this link for abstract

Date of publication: June 2011

Publication type: journal article

In a nutshell: This article looks at 2 approaches to patient safety within the NHS – promoting accountability & promoting learning lessons from previous mistakes and near-misses.  These approaches can sometimes be conflicting however, the article looks at how these approaches can work together.

Length of publication: 19 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.

Acknowledgements:  CINAHL

Keywords: 

Categories:  Volume 2 Issue 6;


Keeping patients safe when they transfer between care providers

July 28, 2011

Source: Royal Pharmaceutical Society

Follow this link for fulltext

Date of publication: July 2011

Publication type: Guidance

In a nutshell: This guidance looks at the one of the risks to patient care when the patient is transferred between health care providers.   This risk is the miscommunication or unintended change to medications.  The guidance looks at ways to reduce this risk and reduce preventable incidences.

Length of publication: 11 pages

Acknowledgements:  Kings Fund blog


Safety of clinical systems: Health Foundation finds cause for concern

July 28, 2011

Source: British Journal of Nursing Volume 20 Issue 8 p517-518

Follow this link for abstract

Date of publication: May 2011

Publication type: Journal article

In a nutshell: run in parallel with the Health Foundation’s ‘Safer clinical systems programme’ this report looked at clinical systems, and how they affect care.  The ‘Safer clinical system programme’ also tested and demonstrated improvements which can be made to healthcare systems which can make care safer.

Length of publication: 1 page

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text.  Follow this link to find your local NHS Library


Adverse drug reactions: ‘six rights’ to ensure best practice for children

July 28, 2011

Source: Nursing Children & Young People  vol 23, iss 5 p2046-2050

Follow this link for abstract

Date of publication: Jun 2011

Publication type: Journal article

In a nutshell:  This article looks at the ‘six rights’ governing the safety in administration issued by the National Patient Safety Agency in regards to adverse drug reactions in children and young people.

Length of publication: 4 pages

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text.  Follow this link to find your local NHS Library

Acknowledgements:  BNI


BMJ Analysis: Why patient safety is such a tough nut to crack

July 28, 2011

Source:   BMJ  Volume 342, d3447

Follow this link for abstract

Date of publication:  June 2011

Publication type:   Journal article

In a nutshell:  While patient safety is on the forefront of health care worldwide there are still a high number of preventable adverse incidents causing patient harm.  This article looks at four challenges to patient safety and the implementation of interventions – visibility; ambiguity; complexity and autonomy.

Length of publication:  1 web page

Some important notes:  This article is available in full text to all NHS Staff using Athens, for more information about accessing full text.  Follow this link to find your local NHS Library

Acknowledgements:  NELM News service


Further dissemination

July 28, 2011

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