Patient Safety Horizon Scanning Volume 4 Issue 8

August 29, 2013
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Engaging senior doctors in patient safety training

August 29, 2013

Source:  The Health Foundation

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Date of publication:  July 2013

Publication type:  News item

In a nutshell:  In an article entitled, “Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors”, the authors explore engaging senior doctors in patient safety training, as both teachers and learners. There have been calls for patient safety to be included in the learning of all healthcare workers and senior clinicians are a key audience for this learning. Patient safety is a relatively new discipline so many senior clinicians have not been exposed to it as part of their training, but they could be used as an ‘expert faculty’ to drive and support the teaching of patient safety among all healthcare workers.

Length of Publication:  1 web page


Berwick review into patient safety

August 29, 2013

Source:  Department of Health

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Date of publication:  August 2013

Publication type:  Report

In a nutshell:  The main problems affecting patient safety in the NHS are highlighted in this report, by Professor Don Berwick, an international expert in patient safety, and there are recommendations made to address them. The report states that the health system must recognise the need for system wide change and insist on the primacy of working with patients and carers to achieve health care goals. It also says that the NHS needs to ensure that the responsibility for functions related to safety and improvement are established clearly and simply.

Length of Publication:  1 web page


Developing a patient measure of safety (PMOS)

August 29, 2013

Source:  BMJ Quality and Safety vol./iss 22/7 pp. 554-562

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Date of publication:  July 2013

Publication type:  Journal article

In a nutshell:  In high-risk industries, tools that can identify factors that contribute to accidents have been developed. Patients provide feedback on their experience of care in hospitals, but there are no existing measures asking patients to comment on issues that can lead to patient safety incidents. This study aimed to define  contributory factors from the Yorkshire Contributory Factors Framework (YCFF) that patients are able to identify in a hospital setting and to use this information to develop a patient measure of safety (PMOS). The draft PMOS worked well and showed that patients are able to identify factors which contribute to the safety of their care.

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.


NICE guidance supports use of a device to visualise the airway in emergencies and improve patient safety

August 29, 2013

Source:  National Institute for Health and Care Excellence

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Date of publication:  July 2013

Publication type:  News item

In a nutshell:  NICE has published guidance to support the use of a device to help health professionals keep patients’ airways open when unexpected problems occur during procedures. The guidance advises that Ambu aScope2 can help health professionals when there are unexpected difficulties in positioning a temporary tube to keep the airway open, and emergency action is needed to maintain the airway. A thin, single-use, flexible endoscope, Ambu aScope2 uses video camera technology to help health professionals see the windpipe clearly.

Length of Publication:  1 web page


Medication discrepancies at transitions in pediatrics: a review of the literature

August 29, 2013

Source:  Pediatric Drugs vol/iss 15/3, pp. 203-215

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Date of publication:  June 2013

Publication type:  Journal article

In a nutshell:  Many countries, including the UK, have incorporated medication reconciliation as an important theme for national patient safety initiatives and objectives. The pediatric population are excluded from UK national guidance. This review aimed to discover the occurrence of medication discrepancies in the pediatric population. Small scale studies show that medication discrepancies occur at all transitions of care in children. To investigate and establish how implementing medication reconciliation can reduce discrepancies and prevent potential harm to patients, further research is needed.

Length of Publication:  13 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.


Development and content validation of a surgical safety checklist for operating theatres that use robotic technology

August 29, 2013

Source:  BJU International vol/iss 111/7 pp.1161-74

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Date of publication:  June 2013

Publication type:  Journal article

In a nutshell:  The objective of this study was to identify potential hazards in robot-assisted urological surgery and to develop a checklist to be used in operating theatres with robotic technology. A risk assessment tool, Healthcare Failure Mode and Effects Analysis (HFMEA), was employed in a urology operating theatre with robotic technology in a UK teaching hospital in 2011. A multidisciplinary team identified ‘failure modes’ and potential hazards were rated according to severity and frequency and scored using a ‘hazard score matrix’. HFMEA identified hazards in the operating theatre and this led to the development of a surgical safety checklist.

Length of Publication:  14 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.