Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population

February 24, 2016

Source:  International Journal for Quality in Healthcare [Epub ahead of print]

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population.

The authors conclude that this study demonstrates that a framework for patient safety can be applied to facilitate the organisation and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardised framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.

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


Accounting for actions and omissions: a discourse analysis of student nurse accounts of responding to instances of poor care

February 24, 2016

Source:  Journal of Advanced Nursing [epub ahead of print]

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Date of publication:  January 2016

Publication type:  Journal article

In a nutshell:  Failure to report cases of poor care may have serious consequences for patient safety. The aim of this study was to explore how nursing students account for decisions to report or not report poor care witnessed on placement and to examine the implications of findings for educators.

The findings were that participants took care to present themselves in a positive light regardless of whether or not they had reported an episode of concern. Those who had reported tended to attribute their actions to internal factors such as moral strength and a commitment to a professional code. Those who had not or would not report concerns provided accounts which referred to external influences that prevented them from doing so or made reporting pointless.

This study provides information about how students account for their actions and omissions in relation to the reporting of poor care. Findings suggest ways educators might increase reporting of concerns.

Length of publication:  Unspecified


Aviation and healthcare: a comparative review with implications for patient safety

February 24, 2016

Source:  Journal of the Royal Society of Medicine 0/0 pp. 1-10

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Date of publication:  January 2016

Publication type:  Journal article

In a nutshell:  Safety in aviation has often been compared with safety in healthcare. The UK government recently set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, the authors have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare have been derived and documented.

The authors conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

Length of publication:   10 pages


Changing the default to promote influenza vaccination among health care workers

February 24, 2016

Source:  Vaccine [Epub ahead of print]

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Date of publication:  February 2016

Publication type:  Journal article

In a nutshell:  Influenza vaccination uptake among health care workers (HCWs) is the most effective method to prevent transmission to patients, but vaccination coverage rates are low among HCWs. Several educational campaigns have been developed to increase the influenza vaccination coverage rates of HCWs, but showed only small effects. The aim of this study was to test an opt-out strategy in promoting uptake among HCWs in a tertiary care center for patients with complex chronic organ failure.

HCWs in the opt-out condition were more likely to have an appointment for influenza vaccination, which in turn increased the probability of getting vaccinated.  Therefore, the authors concluded that changing the default to promote influenza vaccination among HCWs might be an easy and cost-effective alternative to complex vaccination campaigns.

Length of publication:  1 webpage


Patient Safety & Congress Awards 2016

February 24, 2016

Source:  Patient Safety Congress & Awards

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Date of publication: February 2016

Publication type:  Website

In a nutshell:  The Patient Safety Congress 2016, 5 – 6 July, is to be held in Manchester and the theme is inspiring our workforce: finding solutions with staff and patients. The conference will showcase the best work from across the UK, using innovative, proven solutions to tackle everything from large-scale redesign of emergency services to reduce readmissions to new approaches to cost-effective patient-led decision making.

Length of publication:  1 webpage


Further dissemination

February 24, 2016

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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