Patient Safety Horizon Scanning Volume 6 Issue 1

January 28, 2015

New patient safety incentives revealed

January 28, 2015

Source:  Health Service Journal, 5 January 2015

Follow this link for abstract

Date of publication:  January 2015

Publication type:  News item

In a nutshell:  NHS England has presented new incentives to improve patient safety. The incentives include advances in seven day services, care of sepsis and acute kidney injury, and moves to tackle antibiotic resistance.

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


Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study

January 28, 2015

Source:  BMJ Quality & Safety 23/12 pp. 1007-13

Follow this link for abstract

Date of publication:  December 2014

Publication type:  Journal article

In a nutshell: This study says that the built environment in acute care settings is a new focus in patient safety research. This was an interventionist video-reflexive ethnographic (VRE) study, exploring how clinicians used the built environment to achieve safe communication in an intensive care unit (ICU) in a hospital in Sydney. The authors found that ICU staff enable safe communication in their wards by creating temporary spaces that are both ‘connected’ and ‘protected’.

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


Improving communication with primary care to ensure patient safety post-hospital discharge

January 28, 2015

Source:  British Journal of Hospital Medicine (Lond). 76/1 pp. 46-9

Follow this link for abstract

Date of publication:  January 2015

Publication type:  Journal article

In a nutshell: Discharge summaries are the easiest way for GPs to obtain information about a patient’s hospital stay. A quality improvement study was conducted with the aim of increasing the content of discharge summaries for inpatients. A prospective review of 60 electronic discharge summaries was conducted over a 6-week period. The content of discharge summaries was reviewed in accordance with local trust guidelines. Targeted, intensive, cost and time-effective educational interventions were conducted. The authors say that simple, intensive educational sessions can lead to an improvement in discharge summaries and communication with primary care.

Length of Publication:  4 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


Errors in the management of cardiac arrests: An observational study of patient safety incidents in England

January 28, 2015

Source:  Resuscitation 85/12 pp.1759–1763

Follow this link for abstract

Date of publication:  December 2014

Publication type:  Journal article

In a nutshell: This study aimed to gain a better understanding of the types of error that occur during the management of cardiac arrests that lead to a death. The reviewers identified a main shortfall in the management of each cardiac arrest and this resulted in 12 different factors being documented. These were then grouped into four themes: miscommunication involving crash number, shortfalls in staff attending the arrest, equipment deficits, and poor application of knowledge and skills. No firm conclusion could be drawn about how many deaths would have been averted if the emergency had been managed to a high standard.

Length of Publication:  5 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


Project JOINTS: What factors affect bundle adoption in a voluntary quality improvement campaign?

January 28, 2015

Source:  BMJ Quality & Safety 24/1 pp.38-47

Follow this link for abstract

Date of publication:  January 2015

Publication type:  Journal article

In a nutshell:  This article looks at how hospital adherence to quality improvement (QI) methods and hospital engagement with a large-scale QI campaign could facilitate the adoption of an enhanced prevention bundle designed to reduce surgical site infection (SSI) rates after orthopaedic surgery. Project JOINTS (Joining Organizations IN Tackling SSIs) is a QI campaign run by the Institute for Healthcare Improvement (IHI). The campaign encouraged hospitals to implement an enhanced SSI prevention bundle. Adherence to the QI methods and hospital engagement were positively associated with complete bundle adoption.

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


GMC publishes reports on patient safety and bullying

January 28, 2015

Source:  NHS Employers

Follow this link for item

Date of publicationDecember 2014

Publication type:  News item

In a nutshell: The General Medical Council (GMC) has published two reports on patient safety and bullying. The reports discuss issues raised in the 2014 national training survey. The Concerns about patient safety report revealed that local reporting systems within local education providers (LEPs) are mainly effective. There were some concerns about the lack of information given on how to raise concerns, who to report to and a lack of confidence in the local systems for reporting concerns. The report provides a number of case studies describing how these issues are investigated and resolved.

Length of Publication:  1 web page