Patient Safety Horizon Scanning Volume 4 Issue 4

April 26, 2013

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The measurement and monitoring of safety

April 26, 2013

Source:  The Health Foundation

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Date of publication:  April 2013

Publication type:  Report

In a nutshell:  There is now a great awareness of the problem of medical harm, and significant efforts have been made to improve the safety of healthcare. The authors have synthesised available evidence and have proposed a single framework that brings together a number of conceptual and technical facets of safety. This framework highlights five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a widespread and rounded picture of an organisation’s safety. The dimensions are past harm, reliability, sensitivity to operations, anticipation and preparedness, and integration and learning.

Length of Publication:  92 pages


Latest patient data shows improvement in reporting

April 26, 2013

Source:  NHS England

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Date of publication:  March 2013

Publication type:  Press release

In a nutshell:  NHS England has released the National Reporting and Learning System (NRLS) Organisation Patient Safety Reports. The reports show progress in the reporting of patient safety incidents from April to September 2012.

Length of Publication:  1 web page


Ensuring patient safety blood transfusion

April 26, 2013

Source:  Nurs Times Vol/iss 109/4 pp. 22-3.

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Date of publication:  January-February 2013

Publication type:  Journal article

In a nutshell:  This paper discusses the fact that blood transfusion is a common procedure, that it carries a degree of risk, and that avoidable mistakes can result in serious or fatal consequences. Adverse events are largely associated with human error so current knowledge and skills of the blood grouping system and compatibility, and the ability to identify, respond to and report reactions, are essential for patient safety. An online Nursing Times Learning unit on safe blood transfusion is being launched soon.

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.


Safety culture: What is it and how do we monitor and measure it?

April 26, 2013

Source:  The Health Foundation

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Date of publication:  March 2013

Publication type:  Report

In a nutshell:  A report from a roundtable event hosted by the Health Foundation in February to discuss what is understood as ‘safety culture’, why it is significant and how it can be measured and monitored. The event was held as part of the Health Foundation’s work to lead a change in thinking about patient safety. There is a summary of the discussion and the themes that should be explored further.

Length of Publication:  6 pages


‘Sim Man’ the dummy shortlisted for Patient Safety award for East London NHS Trust

April 26, 2013

Source: The Docklands & East London Advertiser, 29 March 2013

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Date of publication:  March 2013

Publication type: Press release

In a nutshell: Sim Man, a medical device with computer-controlled simulation technology, is being used by the East London NHS Foundation Trust for their ‘dummy run’ medical refresher practice. The dummy lets nurses and other medical staff refresh their skills or learn new ways of doing things without having to practice on real patients. Sim Man has now been shortlisted for a Patient Safety award.

Length of publication: 1 web page


Patient safety in vitreoretinal surgery: quality improvements following a patient safety reporting system

April 26, 2013

Source:  Br J Ophthalmol. Vol/iss 97/3 pp. 302-7.

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Date of publication:  March 2013

Publication type:  Journal article

In a nutshell:  Vitreoretinal (VR) surgery is complex and many clinical conditions that VR surgeons manage have a high risk for blindness or severe visual impairment. The authors examined the role of PSI reporting in making VR surgery safer at their institution. VR PSI reporting resulted in a change in clinical practice. Longitudinal analysis suggests an accompanying increase in patient safety.

Length of Publication:  6 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.