Patient Safety Horizon Scanning Volume 7 Issue 2

February 24, 2016
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Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system

February 24, 2016

Source:  Journal of Patient Safety

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study’s objective was to document such an association across an entire hospital system and across multiple harm types.

Length of publication:  Unspecified

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 the governance of patient safety in emergency care: a systematic review of interventions

February 24, 2016

Source:  BMJ Open 6/1

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Date of publication:  January 2016

Publication type:  Systematic review

In a nutshell:  The objective of this study was to systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.

The conclusions were that the characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in emergency medical services organisations and emergency departments. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base.

Length of publication:  1 webpage


Patient safety alert – Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus

February 24, 2016

Source:  NHS England

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Date of publication: February 2016

Publication type:  Safety alert

In a nutshell:  A patient safety alert has been issued by NHS England to raise awareness of the risk of severe dehydration and death caused by an omission or delay of desmopressin in patients with cranial diabetes insipidus.

Following reports of patient safety incidents caused by an omission or delay in the provision of desmopressin, providers of NHS care are asked to consider if immediate action needs to be taken locally to raise awareness and reduce the risk of these incidents from occurring. The main themes identified as causes include a lack of awareness of the critical nature of desmopressin amongst medical, pharmacy and nursing staff; and poor availability of the medication within inpatient clinical areas.

Length of publication:   1 webpage


Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study

February 24, 2016

Source:  BMJ Open 6/e008751 pp. 1-7

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  To examine associations between mortality and registered nurse (RN) staffing in English hospital trusts taking account of medical and healthcare support worker (HCSW) staffing.

Ward-based RN staffing is significantly associated with reduced mortality for medical patients. There is little evidence for beneficial associations with HCSW staffing. Higher doctor staffing levels is associated with reduced mortality. The estimated association between RN staffing and mortality changes when medical and HCSW staffing is considered and depending on whether ward or trust wide staffing levels are considered.

Length of publication:  7 pages


Responding to concerns

February 24, 2016

Source:  Health Education England

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Date of publication: January 2016

Publication type:  Video

In a nutshell:  ‘Responding to Concerns’, is a new educational film developed by Health Education England that aims to improve patient safety. Developed with input from patient safety experts, including our raising concerns network, the film aims to equip staff with the knowledge, skills and confidence to adequately and safely respond to patient safety concerns.

Length of publication:  1 webpage


How might health services capture patient-reported safety concerns in a hospital setting? An exploratory pilot study of three mechanisms

February 24, 2016

Source:  BMJ Quality & Safety

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Date of publication: February 2016

Publication type:  Original research

In a nutshell:  Emergent evidence suggests that patients can identify and report safety issues while in hospital. However, little is known about the best method for collecting information from patients about safety concerns. This study presents an exploratory pilot of three mechanisms for collecting data on safety concerns from patients during their hospital stay.

The results of the study were that significantly more safety concerns were elicited from patients in face-to-face interviews condition compared with the paper-based form and the patient safety hotline. The authors concluded that interviewing at the patient’s bedside is likely to be the most effective means of gathering safety concerns from inpatients, potentially providing an opportunity for health services to gather patient feedback about safety from their perspective.

Length of publication:  Unspecified

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