Patient Safety Horizon Scanning Volume 5 Issue 10

October 29, 2014

Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review

October 29, 2014

Source:  BMC Health Services Research 14/1 pp.369

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: The authors of this review assessed the impact of hospital and system-wide interventions to improve patient safety. Studies which measured outcomes two years after implementation or more were more likely to show improved outcomes. It was difficult to assess the impact of organisational culture or other determinants. Effective leadership and clinical champions, adequate financial and educational resources and dedicated promotional activities may have a significant impact.

Length of Publication:  1 web page


Nurses’ shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety

October 29, 2014

Source:  Medical Care 52/ 11 pp.975-81.

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell:  This article aimed to describe shift patterns of European nurses and to investigate whether shift length and working overtime is associated with nurse-reported care quality, safety, and care left undone. The authors concluded that European registered nurses working shifts of ≥12 hours and those working overtime reported lower quality and safety and more care left undone. Any policies to adopt a 12-hour nursing shift pattern should proceed with caution. Use of overtime working to help with staffing shortages or increase flexibility also incurs additional risk to quality.

Length of Publication:  1 web page

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


New patient safety Collaboratives launched

October 29, 2014

Source:  National Health Executive

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Date of publication:  October 2014

Publication type:  News item

In a nutshell: A new national programme to improve patient safety will see the establishment of 15 Patient Safety Collaboratives – each led by an Academic Health Science Network (AHSN). Each Collaborative will be funded for the next five years by NHS England. The Collaboratives will support individuals, teams and organisations to build skills and knowledge about patient safety and quality improvement. The Collaboratives are aligned with, and support, the ‘Sign up to Safety’ campaign to make the NHS the safest healthcare system in the world.

Length of Publication:  1 web page


NHS England publishes Never Events Policy Framework Review consultation online

October 29, 2014

Source:  NHS England

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Date of publication:  October 2014

Publication type:  News item

In a nutshell: NHS England has published the Never Events Policy Framework Review consultation. The consultation will help to show what needs to be done, and by whom, to prevent never events. Part of the review will also consider financial penalties for never events, and how this might be included in the NHS Standard Contract for 2015/16. The review is focusing on five key issues: the purpose, definition, list of, management, and application of learning from never events. The overall aim of the review is to keep patient safety as a focus for action, and to foster a culture which aims to share learning and improve, rather than to blame and penalise.

Length of Publication:  1 web page


A strategy to maintain safety in clinical incidents

October 29, 2014

Source:  Nursing Times 2/110 (34-35) pp.16-8.

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Date of publication:  August 2014

Publication type:  News item

In a nutshell:  Team leaders in the NHS are often in a position where they have to manage and control a clinical situation. They can also be actively involved in delivering patient care because of low staffing levels or inappropriate skill mixes, which can lead to the potential for loss of situational awareness and risk to patient and staff safety. “Inner and outer circles” is an approach that could reduce risks and increase patient safety. It is used in pre-hospital and industrial environments and could be adapted to suit inpatient and other settings.

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


The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study

October 29, 2014

Source:  BMC Health Services Research 14 pp. 432

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: There is evidence that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to the reasonable adjustments that they need not being implemented. This article aimed to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities. It describes the patient safety issues that patients with intellectual disabilities in NHS acute hospitals encounter and investigates underlying contributory factors. The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents.

Length of Publication:  1 web page