Patient Safety Horizon Scanning Volume 5 Issue 7

‘How Safe is my Hospital’ site launched

Source:  EHealth Insider

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Date of publication:  June 2014

Publication type:  News item

In a nutshell:   This news reports on a new section on NHS Choices which will include Trust compliance on ward staffing, incident reporting, pressure ulcers, falls and patient safety. The Department of Health has launched the site, which will enable the public to compare hospitals in England based on a number of safety indicators. The launch is part of the ‘Sign up to Safety’ campaign that aims to save up to 6000 lives over the next three years. The trusts will be ranked according to how openly they are reporting and will be rated as ‘good’, ‘acceptable’ or ‘poor’. As part of the campaign, Jeremy Hunt has also launched a new Safety Action for England team, made of senior clinicians, managers and patients.

Length of Publication:  1 web page

Codifying knowledge to improve patient safety: A qualitative study of practice-based interventions

Source:  Social Science and Medicine 113 pp. 169-176

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Date of publication:  June 2014

Publication type:  Journal article

In a nutshell:  Knowledge codification is the conversion of implicit or tacit knowledge to explicit knowledge so that it is effective for making change. Patient safety interventions were implemented by two NHS hospitals through the codification of knowledge. One hospital introduced a structured mortality review process and another hospital used a medication safety scorecard on a general medicine and elderly care ward. Codification helped staff learn about patient safety by structuring the sharing of tacit knowledge. Good organisational governance and support is needed to help translate knowledge across levels.

Length of Publication:  8 pages

New checklist makes the cardiac catheterisation lab a safer place for patients

Source:  The Health Foundation

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Date of publication:  June 2014

Publication type:  News item

In a nutshell: A Shine-funded project at Royal Brompton and Harefield NHS Foundation Trust set out to develop a safety checklist for the cardiac catheterisation laboratory (CCL) in 2013. The World Health Organisation (WHO) safe surgery checklist was used to create the checklist, but it was specifically modified for use in the CCL. Staff liked using the checklist and said they would like one used if they ever needed an intervention themselves. The team achieved 95% implementation of all stages of the checklist. The checklist created a collaborative atmosphere where team members better understood their roles and had more opportunities to raise concerns. Almost 60% of patients noticed staff implementing the checklist and felt safer knowing that it was being used. The team is exploring the possibility of implementing a checklist in emergency scenarios. The British Cardiovascular Society has encouraged national dialogue by publishing new guidance about the use of safety procedure checklists in the CCL.

Length of Publication:  1 web page

Development of a knowledge, skills, and attitudes framework for training in laparoscopic cholecystectomy

Source:  The American Journal of Surgery 207/5 pp. 790-6

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Date of publication:  May 2014

Publication type:  Journal article

In a nutshell:  Resident education and training has been changed by the implementation of duty-hour restrictions and a heightened awareness of patient safety. The authors of this article discuss the development of a training framework for knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. This curriculum developed a structured framework for surgical training, a method that can be applied to any procedure.

Length of Publication:  7 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.

Improving patient safety through feedback on prescribing errors

Source:  The Health Foundation

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Date of publication:  June 2014

Publication type:  Webinar

In a nutshell: Discusses a case study video from Imperial College Healthcare NHS Trust. Bryony Dean Franklin from the Trust talks about the Shine 2012 project, which aimed to improve patient safety through feedback on prescribing errors. In UK studies of the causes of prescribing errors, a common theme is that junior doctors are often unaware of making errors and receive little feedback on errors and how to prevent them. According to research, providing feedback on aspects of clinical performance can improve quality of care and lead to professional behaviour change. There is little experience with this approach in the UK hospital setting though so this project proposed a practical low-cost intervention building on hospital pharmacists’ existing practice to identify and rectify prescribing errors.

Length of Publication:  1 web page

Learning from the design and development of the NHS Safety Thermometer

Source:  International Journal of Quality in Health Care 26/3 pp. 287-297

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Date of publication:  June 2014

Publication type:  Journal article

In a nutshell:  The NHS Safety Thermometer has been developed to measure the prevalence of harm from pressure ulcers, falls and urinary tract infections in people with catheters and venous thromboembolism on one day each month. It is for all NHS patients. The tool was developed during a learning collaborative between 161 organisations and tested over a 17 month period, with 73,651 patient entries. The researchers determined that it is possible to obtain national data using a standardised tool completed by site coordinators. It is important that data collectors are well trained.

Length of Publication:  11 pages

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