Patient Safety Horizon Scanning Volume 7 Issue 3

March 23, 2016

Patient safety incidents associated with failures in communication reported from critical care units in the North West of England between 2009 and 2014

March 23, 2016

Source:  Journal of the Intensive Care Society [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Communication is central to the safe and effective delivery of critical care. This article presents a retrospective analysis of hospital incident reports attributed to communication that were generated by 30 intensive care units in the North West of England from 2009 to 2014. The study reviewed when during the critical care pathway incidents occur, the personnel involved, the method of communication used, the type of information communicated and the level of harm associated with the incident. The study found that patient safety incidents tend to occur when patients are transferred into or out of the intensive care unit and when information has to be communicated to other teams during the critical care stay. Ways that the patient handover process may be modified to improve communication and safety are also examined.

Length of publication:  1 webpage


The commission on education and training for patient safety: improving patient safety through education and training

March 23, 2016

Source:  Health Education England

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Date of publication: March 2016

Publication type:  Report

In a nutshell:  Produced by the Commission on Education and Training for Patient Safety and supported by Imperial College the report sets out ambitions, the case for change, what is working well including case studies and where improvements need to be made to make the greatest difference to patient safety both now and in the future. It sets out the future of education and training for patient safety in the NHS over the next ten years, making twelve recommendations to Health Education England and the wider system.

Length of publication:  60 pages


Safety standards for invasive procedures: beware the implementation gap

March 23, 2016

Source:  BMJ 352:i1121

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Nick Sevdalis is professor of implementation science and patient safety at King’s College London.  In this editorial he offers advice regarding the implementation of the recent NHS England guideline National Safety Standards for Invasive Procedures (NatSSIPs).  

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


Simulation-based training: the missing link to lastingly improved safety and health?

March 23, 2016

Source: Postgraduate Medical Journal [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Medical education has traditionally relied on on-the-job training. However, the often used ‘see one, do one, teach one’ approach may be detrimental to patient safety and health, as it exposes patients to inexperienced healthcare practitioners. In an effort to reduce human errors and improve operational safety, simulation-based training (SBT) has been recognised as an effective methodology.

Contents of SBT include conceptual understanding, technical skills, decision-making skills, and attitudes and behaviours summarised as teamwork. Thus, theoretical advantages of SBT over traditional educational methodologies are manifold. This article reviews available evidence about the effectiveness of SBT of technical and non-technical skills with regard to improvements in medical care, patient safety and health.

Length of publication:  3 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


International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

March 23, 2016

Source:  BMJ Quality & Safety [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care.  This study used a Delphi approach to determine consensus regarding the ideal role of PSRSs and to devise recommendations for best practice.

The study resulted in reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

Length of publication:  14 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 distractions in the operating room on clinical decision-making and patient safety

March 23, 2016

Source: Surgical Endoscopy [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Answering telephone calls and pagers is common distraction in the operating room. This study sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance.

The study found that distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents’ ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

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


Researchers’ roles in patient safety improvement

March 23, 2016

Source:  Journal of Patient Safety 12/1 pp. 25–33

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Date of publication: March 2016

Publication type:  Journal article

In a nutshell:  This article explores how researchers can contribute to patient safety improvement with the aim of expanding the instrumental role researchers have often occupied in relation to patient safety improvement.

The conclusions were that when working side by side with “practice,” researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds—as well as other actors involved in patient safety improvement—in structuring their work and collaborating productively.

Length of publication:  9 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


Patient safety and the problem of many hands

March 23, 2016

Source: BMJ Quality & Safety [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Healthcare worldwide is faced with a crisis of patient safety. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. The authors of this article propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors—organisations, individuals, groups—each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. This paper calls for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.

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


The daily relationships between staffing, safety perceptions and personality in hospital nursing: a longitudinal on-line diary study

March 23, 2016

Source: International Journal of Nursing Studies 59 pp. 27–37

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Date of publication: March 2016

Publication type:  Journal article

In a nutshell:  The association between poor staffing conditions and negative patient safety consequences is well established within hospital nursing. However, many studies have been limited to nurse population level associations, and have used routine data to examine relationships. As a result, it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis. Furthermore, personality may have direct and moderating roles in terms of work environment and patient safety associations, but limited research has explored personality in this context.

The findings elucidate the potential mechanisms by which patient safety risks arise within hospital nursing, and suggest that nurses may not respond to staffing conditions in the same way, dependent upon personality. Further understanding of these relationships will enable staff to be supported in terms of work environment conditions on an individual basis.

Length of publication:  11 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 the safety of vaccine delivery

March 23, 2016

Source:  Human Vaccines & Immunotherapeutics [Epub ahead of print]

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Vaccines save millions of lives per annum and are an integral part of community primary care provision worldwide. The World Health Organization has highlighted that the adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst it is known that as many as one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and drug adverse event surveillance systems are proving useful informants for understanding the underlying causes of those errors. The challenge now lies in the identification and implementation of changes to improve vaccine safety at multiple levels: from patient level interventions through to organisational efforts at local, national and international levels. The authors consider the potential benefits for maximising learning from patient safety incident reports to improve the quality and safety of care delivery.

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


Blood transfusion: patient identification and empowerment

March 23, 2016

Source: British Journal of Nursing 25/3

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Date of publication: February 2016

Publication type:  Journal article

In a nutshell:  Positive patient identification is pivotal to several steps of the transfusion process; it is integral to ensuring that the correct blood is given to the correct patient. If patient misidentification occurs, this has potentially fatal consequences for patients. Historically patient involvement in healthcare has focused on clinical decision making, where the patient, having been provided with medical information, is encouraged to become involved in the decisions related to their individualised treatment. This article explores the aspects of patient contribution to patient safety relating to positive patient identification in transfusion. When involving patients in their care, however, clinicians must recognise the diversity of patients and the capacity of the patient to be involved. It must not be assumed that all patients will be willing or indeed able to participate. Additionally, clinicians’ attitudes to patient involvement in patient safety can determine whether cultural change is successful.

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