Patient Safety Horizon Scanning Volume 3 Issue 7

December 3, 2012
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Updated never events policy framework and data published

December 3, 2012

Source: Department of Health

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Date of publication: October 2012

Publication type: Policy document

In a nutshell: To address areas of uncertainty and provide greater clarity about never events and the recommended response to them following feedback from stakeholders, the never events policy framework has been reviewed and updated. It is a useful reference for clinicians, other staff and patients. The update contains data on the number and types of never event reported in the last two years.

Length of publication: 1 web page


NPSA publishes patient safety incident data update

December 3, 2012

Source: National electronic Library for Medicines

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Date of publication: 13 September 2012

Publication type: News item

In a nutshell: Data workbooks covering organisation patient safety incident reports data for incidents that occurred between 1 October 2011 and 31 March 2012 and were reported to the National Reporting and Learning System (NRLS) by 31 May 2012 have been issued by the National patient Safety Agency (NPSA). Workbooks covering data by region and data by organisation are available.

Length of publication: 1 web page


Strategies for sustaining a quality improvement collaborative and its patient safety gains

December 3, 2012

Source:  International Journal for Quality in Health Care, vol./is. 24/4 pp.380-90

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Date of publication:  August 2012

Publication type:  Journal article

In a nutshell:  This qualitative interview study aimed to identify strategies to facilitate the sustainability of a quality and safety improvement collaborative entitled the Safer Patients Initiative (SPI) and its successes. The study presents the key strategies that principle programme coordinators across 20 NHS organizations consider to be key in order to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on.

Length of Publication:  11 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.


Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study

December 3, 2012

Source:  BMJ Quality & Safety, vol./is. 21/10 pp. 810-8

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Date of publication:  October 2012

Publication type:  Journal article

In a nutshell:  The evidence base describing safety hazards in the cardiovascular operating room is weak, but essential to guide future safety improvement efforts. The aim of this paper was to identify and categorise hazards (anything that has the potential to cause a preventable adverse patient safety event) in the cardiovascular operating room. The future focus should be on creating a stronger culture of safety, increasing compliance with evidence-based infection control practices and improving communication and teamwork.

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.


Impact of a structured template and staff training on compliance and quality of clinical handover

December 3, 2012

Source:  International Journal of Surgery, vol/iss 10/9 pp.571-574

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Date of publication:  October 2012

Publication type:  Journal article

In a nutshell:  In this article, researchers assessed whether the quality of clinical handover in hospital could be improved for junior doctors by using a standardised and structured handover template. A computerised template was developed in accordance with handover guidelines by the Royal College of Surgeons of England. The template helped to promote quality of care, improve compliance to agreed standards and protect patient safety.

Length of Publication:  4 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:  The Heath Foundation


Improving patient safety

December 3, 2012

Source: Worcester News

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Date of publication: November 2012

Publication type: News item

In a nutshell: A team has been set up at Worcestershire Acute Hospitals NHS Trust to improve patient safety by eliminating blood clots, falls, bed sores and urinary catheter infections. The safe care team, launched in August, has been working across county hospitals, including Worcester. The scheme has already had some successes including Ward 11 at the Alexandra Hospital, Redditch, where there have now been 130 days without a patient developing a pressure ulcer.

Length of publication: 1 web page