Patient Safety Horizon Scanning Volume 6 Issue 4

April 29, 2015
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Serious Incident Framework

April 29, 2015

Source:  NHS England

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Date of publicationMarch 2015

Publication type:  News item

In a nutshell: The revised Serious Incident Framework from NHS England provides renewed guidance to help organisations respond to serious incidents appropriately.

Length of Publication:  1 web page


Revised Never Events Policy and Framework

April 29, 2015

Source:  NHS England

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Date of publicationMarch 2015

Publication type:  News item

In a nutshell: The revised Never Events Policy and Framework from NHS England, includes changes to the definition of a never event and adjustments to the never events list.

Length of Publication:  1 web page


MPs call for new national patient safety body to lead clinical accident investigations

April 29, 2015

Source:  BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h1707 (Published 30 March 2015)

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Date of publicationMarch 2015

Publication type:  News item

In a nutshell: MPs say that an independent national investigator of clinical accidents should be created to improve on the speed, quality, and thoroughness of investigations. MPs of the House of Commons Public Administration Select Committee are asking the next government to make changes to improve the current system for dealing with clinical incidents. In a recent report, the committee called on the next health secretary after the general election to establish a national independent patient safety investigation body. The MPs say this body should be a centre of knowledge and promote good investigatory practice and skills, and investigations should ideally be carried out locally.

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


Safety culture and the 5 steps to safer surgery: an intervention study

April 29, 2015

Source:  British Journal of Anaesthesia pii: aev063. [Epub ahead of print]

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Date of publication:  March 2015

Publication type:  Journal article

In a nutshell:  The 5 Steps to Safer Surgery (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework. This study aimed to identify any changes in safety culture associated with the introduction of the 5SSS in orthopaedic operating theatres. The authors assessed the safety culture in the elective orthopaedic theatres of a large UK teaching hospital before and after introduction of the 5SSS using a modified version of the Safety Attitude Questionnaire – Operating Room (SAQ-OR). They also analysed changes in responses to two items regarding perioperative briefings. The authors conclude that implementation of the 5SSS was associated with a significant improvement in the safety culture of elective orthopaedic operating theatres.

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


Situational Awareness and Its Application in the Delivery Suite

April 29, 2015

Source: Obstetrics & Gynecology 125/1 pp. 65-9

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Date of publication:  January 2015

Publication type:  Journal article

In a nutshell:  The prevention of accidents in the delivery suite relies on the vigilance of the individual practitioner at the frontline. It is important that the individual practitioner should develop and maintain the cognitive skills to anticipate, recognise, and intercept unfolding error events. This article provides an overview of a nontechnical skill that is essential for safe practice in a delivery suite: situational awareness. Strategies and tactics for maintaining situational awareness are discussed. Many of the interventions require minimal financial resources but could immensely enhance clinical performance and patient safety. The article says that situational awareness should be included in the training of obstetrician–gynaecologists and when training other staff working in a delivery suite.

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


Glasgow develops world’s only patient safety programme specifically for mental health

April 29, 2015

Source:  The Herald Scotland

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Date of publicationMarch 2015

Publication type:  News item

In a nutshell: After being recognised for improving patient care, the world’s only national safety programme specifically designed for mental health has been rolled out to 14 wards across NHS Greater Glasgow and Clyde. The mental health arm of the Scottish Patient Safety Programme has seen more patient involvement in decision-making, work on medication safety, wider use of safety briefings at the beginning of shifts, and less use of restraint.

Length of Publication:  1 web page