Patient Safety Horizon Scanning Volume 7 Issue 1

January 27, 2016

Patient safety alert – The risk of using different airway humidification devices simultaneously

January 27, 2016

Source:  NHS England

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Date of publication:  December 2015

Publication type:  Safety alert

In a nutshell: A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare Products Regulatory Agency (MHRA) to raise awareness of the risk of having two different types of airway humidification devices simultaneously connected to a patient’s ventilation equipment.

There are two humidifiers in common use: heated [water] humidifiers (HHs), usually located between the ventilator and the breathing system; and heat and moisture exchangers (HMEs), placed at the patient’s end of the breathing system. The inadvertent use of both types of humidifier simultaneously can cause the HME to become saturated with water and could lead to the airway becoming obstructed.

NHS providers are asked to take local action to prevent the risk.

Length of publication:  1 webpage


Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data

January 27, 2016

Source:  PLOS One

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell: The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.

Length of publication:   8 pages


Simulation in the executive suite: lessons learned for building patient safety leadership

January 27, 2016

Source:  Simulation in Healthcare 10/6 pp. 372-377

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell: This article examines the impact of simulation in building strategic leadership competencies for patient safety and quality among executive leaders in health care organizations. This study illustrates the potential value of simulation as a mechanism for learning and strategy development for executive leaders grappling with patient safety issues. Future research should explore the cognitive or functional fidelity of organizational simulations and the use of custom scenarios for strategic planning.

Length of publication:  6 pages


The missing evidence: a systematic review of patients’ experiences of adverse events in health care

January 27, 2016

Source:  International Journal for Quality in Healthcare 27/6 pp. 423-41

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Date of publication:  December 2015

Publication type:  Systematic review

In a nutshell:  Reviewers from Australia examined patients’ experiences of adverse events. Eight bibliographic databases were searched from January 2000 to February 2015 and 33 studies were included. The most common issues that patients identified with regard to their healthcare were medication errors and issues with communication and coordination of care. Those with higher income levels and education were more likely to report incidents. People said they felt distressed after adverse events and this was exacerbated by not receiving sufficient information about the causes.  The reviewers recommend that information about patients’ experience of adverse events must be routinely captured and utilized to develop effective, patient-centred and system-wide policies to minimise and manage AEs.

Length of publication:  19 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


Which non-technical skills do junior doctors require to prescribe safely? A systematic review

January 27, 2016

Source:  British Journal of Clinical Pharmacology

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Date of publication:  November 2015

Publication type:  Systematic review

In a nutshell:  The aim of this review was to develop a prototype non-technical skills (NTS) taxonomy for safe prescribing, by junior doctors, in hospital settings.  As a result of this research, a prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed.  This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future.

Length of publication:  12 pages


Evaluating the effectiveness of a peer-led education intervention to improve the patient safety attitudes of junior pharmacy students: a cross-sectional study using a latent growth curve modelling approach

January 27, 2016

Source:  BMJ Open

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell:  Researchers in Australia tested using senior pharmacy trainees as peer educators to improve knowledge about patient safety. Junior trainees were surveyed before, immediately after and one month after taking part in a patient safety education programme. Feedback was compared with those who had not taken part. The programme covered introductory patient safety topics including teamwork, communication skills, systems thinking and open disclosure. Two lectures were provided by a lecturer and a workshop was provided by final-year pharmacy students. Trainees’ safety attitudes improved, particularly with regards to questioning behaviours and open disclosure of incidents.

Length of publication:  1 webpage


Human factors in healthcare: welcome progress, but still scratching the surface

January 27, 2016

Source: BMJ Quality and Safety 2015/0 pp. 1-5

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Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  This article investigates the adoption of human factors and ergonomics (HFE) principles within healthcare settings in the UK and the US.  By considering the history, evolution and spread of HFE, the authors hope to enhance translation into healthcare lessons from industry, such as aviation, oil and gas and rail transport, to promote the integration of HFE into healthcare and improve quality of care and patient safety.

Length of publication:  5 pages


Personal hand gel for improved hand hygiene compliance on the regional anesthesia team

January 27, 2016

Source:  Journal of Anesthesia 29/6 pp. 899-903

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Date of publication: December 2015

Publication type:  Journal article

In a nutshell:  A hospital in the US examined the effect of personal gel dispensers for staff on surgical hand hygiene compliance amongst an anaesthesia team. Before personal gel dispensers were provided compliance was 34% (23% before patient contact and 43% afterwards). After personal dispensers, compliance was 63% (53% before patient contact and 72% afterwards).

Length of publication:  5 pages


Using a Lean Six Sigma approach to yield sustained pressure ulcer prevention for complex critical care patients

January 27, 2016

Source:  The Journal of Nursing Administration 46/1 pp. 43-48

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  A hospital in the US used Lean Six Sigma methods to reduce the rate of unit-acquired pressure ulcers in intensive care and step-down units. An interdisciplinary team tested four interventions: standardised documentation, equipment monitoring, monitoring patient movements and a checklist for use on unit rounds. The pressure ulcer rate decreased from 4.4% to 2.8%. This improvement was maintained.

Length of publication:   6 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 diagnosis in health care: the next imperative for patient safety

January 27, 2016

Source:  The New England Journal of Medicine 373/26 pp.2493-2495

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Date of publication:  December 2015

Publication type:  Journal article

In a nutshell:  This is a commentary of the U.S. report Improving Diagnosis in Health Care that acknowledges the need to address diagnostic error as an urgent patient safety issue.  Summarising the goals from the report, this commentary details how the recommendations can lead to enhanced diagnostic safety and reduced patient harm. The authors also acknowledge potential challenges to implementing the systems and process changes described.

Length of publication:   2 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


Further dissemination

January 27, 2016

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