Patient Safety Horizon Scanning Volume 6 Issue 12

December 23, 2015

Patient safety alert – The importance of checking vital signs during and after restrictive interventions/manual restraint

December 23, 2015

Source:  NHS England

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Date of publication:  December 2015

Publication type:  Safety alert

In a nutshell:  A patient safety alert has been issued by NHS England to raise awareness of the importance of taking, recording and responding to vital signs where restraint has been used to manage a person’s behaviour if they are at risk to themselves or others.

Length of publication:  1 webpage


Infection prevention and control: lessons from acute care in England

December 23, 2015

Source:  The Health Foundation

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Date of publication:  November 2015

Publication type:  Report

In a nutshell:  This learning report is based on the findings of a large research study that identified and consolidated published evidence about infection prevention and control initiatives. The researchers synthesised this with findings from qualitative case studies in two large NHS hospitals, including the perspectives of service users. The report considers what has been learned from the infection prevention and control work carried out over the last 15 years in hospitals in England. It looks at the lessons learned and outlines future directions for effective infection prevention and control.

Length of publication:  25 pages


Improving health care quality and safety: the role of collective learning

December 23, 2015

SourceDove Press 2015/7 pp. 91—107

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Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. The review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes.

Length of publication:   17 pages


Staff and public urged to help shape new patient safety body

December 23, 2015

Source:  NHS Networks

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Date of publication:  November 2015

Publication type:  News item

In a nutshell:  NHS staff, patients and members of the public are being urged to have their say on the shape of a new national patient safety organisation.

The health secretary announced in the summer that he would create an independent function to oversee the investigation of patient safety incidents.  An expert advisory group has been established to collect evidence and make recommendations on the roles and responsibilities of the new body, ahead of its formation in April 2016.

An online survey to capture the views of patients and professionals can be found at www.surveymonkey.com/r/ipsis2015

Length of publication:   1 webpage


Situation, background, assessment, and recommendation-guided huddles improve communication and teamwork in the emergency department

December 23, 2015

Source:  Journal of Emergency Nursing 41/6 pp. 484–488

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Date of publication:  October 2015

Publication type:  Journal article

In a nutshell:  A performance-improvement project with the structured processes of a joint patient evaluation and huddle was implemented within a US pediatric emergency department. The following outcomes were measured: presence or absence of joint patient evaluation and SBAR-guided huddle, verbalization of treatment plan, communication, teamwork, and nurse satisfaction. This project showed the feasibility of a simple and inexpensive joint nurse practitioner–registered nurse patient evaluation followed by a structured huddle, which improved communication, teamwork, and nurse satisfaction scores. This performance-improvement project has the potential to enhance efficiency by reducing redundancy, as well as to improve patient safety through the use of structured communication techniques.

Length of publiction:  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


Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives

December 23, 2015

Source:  American Journal of Medical Quality 30/6 pp. 550-8

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Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  Although medical error reporting has been studied, under-reporting remains pervasive. The study aims were to identify the organisational factors with the greatest perceived effect on error reporting and to determine whether associations differ for management and clinical staff.

Error feedback was perceived as the most significant predictor, while organisational learning was another significant factor. It also was found that although management support for patient safety was significantly related to error reporting among clinical staff, this association was not significant among management. This difference is relevant because managers may not be aware that their failure to demonstrate support for safety leads to underreporting by frontline clinical staff. Findings from this study can inform hospitals’ efforts to increase error reporting.

Length of publication:  9 pages