Patient Safety Horizon Scanning Volume 5 Issue 9

October 1, 2014

Patient safety incident reporting continues to improve

October 1, 2014

Source:  NHS England

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Date of publication:  September 2014

Publication type:  News item

In a nutshell: The publication of six-monthly data on patient safety incidents reported to the National Reporting and Learning System (NRLS) between 1 October 2013 and 30 April 2014 shows the NHS is continuing to get better at recognising and reporting patient safety incidents. The increase in the level of reported incidents shows that the NHS is continuing to be more open and transparent about reporting patient safety incidents. Incident reporting is important at a local level because it allows clinicians to learn about why patient safety incidents happen within their own service and organisation, and what they can do to keep their patients safe from avoidable harm.

Length of Publication:  1 web page


The role of hospital managers in quality and patient safety: a systematic review

October 1, 2014

Source:  BMJ Open 4/9 pp. e005055

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Date of publication:  Septemberuly 2014

Publication type:  Journal article

In a nutshell: This article found that the time and effort that hospital managers spend on promoting and assessing quality and safety can influence clinical outcomes and processes. Reviewers from England examined studies about the activities and time hospital managers spend on the quality of care. Most studies were set in the US and focused on Board or senior-level management. Many of the studies used interviews or surveys about perceptions of managerial quality and safety practices.

Length of Publication:  1 web page


East Cheshire implements iPad safety system

October 1, 2014

Source:  Health Service Journal 1, September 2014

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Date of publication:  September 2014

Publication type:  News item

In a nutshell:  An iPad based system funded by the Nursing Technology Fund is being used by nurses at East Cheshire Trust to monitor patient safety. Macclesfield Hospital has begun recording clinical data electronically on handheld devices at the patients’ bedside, replacing the standard practice of recording observations on a paper chart at the end of the bed. Nurses input vital signs and other clinical observations into the devices, and the “VitalPAC” system automatically calculates a risk score which will alert staff immediately to any deterioration and provide advice on an appropriate response. The system is to be rolled out to all inpatient wards at Macclesfield Hospital.

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


Developing eLearning for pressure ulcer prevention and management

October 1, 2014

Source:  British Journal of Nursing 23 Suppl 15:S16-23

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Date of publication:  August 2014

Publication type:  Journal article

In a nutshell:  In April 2012, NHS Greater Glasgow and Clyde (NHS GGC), in line with the Scottish Best Practice Statement for the Prevention and Management of Pressure Ulcers (Quality Improvement Scotland, 2009 ), and the NHS Health Improvement Scotland (2011) Preventing Pressure Ulcers Change Package, launched an awareness campaign throughout the organisation. It has also more recently adopted a ‘zero-tolerance’ approach to pressure damage. The tissue viability service in NHS GGC recognised that education of front-line staff is essential. An educational framework for pressure ulcer prevention was developed for all levels of healthcare staff involved in the delivery of patient care. An initiative to develop web-based eLearning modules has also been taken forward. The modular online education programme addresses the aims of quality improvement and zero tolerance by supporting the provision of safe and effective person-centred care.

Length of Publication:  8 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


Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training

October 1, 2014

Source:  BMJ Quality & Safety Aug 18. [Epub ahead of print]

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Date of publication:  August 2014

Publication type:  Journal article

In a nutshell:  This study aimed to measure the impact of patient narratives used to train junior doctors in patient safety. A trial was conducted in the North Yorkshire East Coast Foundation School (NYECFS). The intervention consisted of 1-h-long patient narratives followed by discussion. The Attitude to Patient Safety Questionnaire (APSQ) and the Positive and Negative Affect Schedule (PANAS) were used to measure the impact of the intervention. The authors state that involving patients with experiences of safety incidents in training has an ideological appeal and seems an obvious choice in designing safety interventions, but that they were unable to demonstrate the effectiveness of the intervention in changing general attitudes to safety compared to control.

Length of Publication:   Unknown

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


Health Education England announces new Board on safety led by Professor Norman Williams

October 1, 2014

Source:  Health Education England

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Date of publication:  August 2014

Publication type:  News item

In a nutshell: A new programme to ensure that patient safety is at the heart of how the health and healthcare workforce are trained has been announced by Health Education England (HEE). Patient safety should be the first and most important lesson healthcare workers learn as they train to work in the NHS. HEE has asked recent past President of the Royal College of Surgeons Professor Norman Williams to chair the new initiative with Sir Keith Pearson, Chair of HEE acting as Vice Chair. The HEE Safety Board will start its work later this year and will look to report in the autumn of 2015.

Length of Publication:  1 web page