Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

February 24, 2016

Source:  Applied Ergonomics Jan/52 pp. 185-95

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

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


How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time

August 26, 2015

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

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Date of publication:  July 2015

Publication type:  Journal article

In a nutshell:  This study aimed to assess whether, compared with previous years, hospital care became safer in 2011/2012, expressing itself in a fall in preventable adverse event (AE) rates alongside patient safety initiatives. The main patient safety initiatives in hospital care at a national level between 2004 and 2012 were small as well as large-scale multifaceted programmes. The study showed some improvements in preventable AEs in the areas that were addressed during the comprehensive national safety programme. There are signs that such a programme has a positive impact on patient safety.

Length of Publication:  1 web page


A multicentre cohort study assessing day of week effect and outcome from emergency appendicectomy

February 26, 2014

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

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Date of publicationFebruary 2014

Publication type:  Journal article

In a nutshell:  Some evidence suggests that patients having treatment at weekends may be subject to different care processes and outcomes compared with weekdays. This study aimed to determine whether clinical outcomes from weekend appendicectomy are different from those performed in the week. A multicentre cohort study was conducted during May-June 2012. The main outcome was the 30-day adverse event rate. The results showed that weekend appendicectomy was not associated with increased 30-day adverse events. Smaller increases that may be shown by larger studies could not be ruled out. Patients operated on at weekends can be subject to different care processes, which may expose them to risk.

Length of Publication:  Unknown

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.


NHS England to review low number of GP patient safety reports

July 31, 2013

Source:  Pulse 9 July 2013

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Date of publication:   July 2013

Publication type:  News item

In a nutshell:  The low numbers of patient safety incidents reported by GPs, which make up 0.5% of all incidents reported in the NHS, is to be investigated by NHS England, in an attempt to encourage practitioners to report adverse events. The General Practitioners Committee (GPC) has explained that it is likely there will be fewer adverse events in general practice, but it said GPs are less likely to report the adverse events because of a ‘blame culture’. A patient safety expert group for primary care is being set up to look into the low number of reports.

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.


Ensuring patient safety blood transfusion

April 26, 2013

Source:  Nurs Times Vol/iss 109/4 pp. 22-3.

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Date of publication:  January-February 2013

Publication type:  Journal article

In a nutshell:  This paper discusses the fact that blood transfusion is a common procedure, that it carries a degree of risk, and that avoidable mistakes can result in serious or fatal consequences. Adverse events are largely associated with human error so current knowledge and skills of the blood grouping system and compatibility, and the ability to identify, respond to and report reactions, are essential for patient safety. An online Nursing Times Learning unit on safe blood transfusion is being launched soon.

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.


Design of a prospective cohort study to assess ethnic inequalities in patient safety in hospital care using mixed methods

January 30, 2013

Source:  BMC Health Services Research, vol/iss 12 450

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Date of publication:  December 2012

Publication type:  Journal article

In a nutshell:  This study aims to assess the risk of adverse events (AEs) for hospitalised patients of non-Western ethnic origin in comparison to ethnic Dutch patients. It looks at the patient-related determinants that may affect the risk of AEs and explores the mechanisms of patient-provider interactions that may increase the risk of AEs. It also explores possible strategies to prevent inequalities in patient safety.

Length of Publication:  20 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.


Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study

December 3, 2012

Source:  BMJ Quality & Safety, vol./is. 21/10 pp. 810-8

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Date of publication:  October 2012

Publication type:  Journal article

In a nutshell:  The evidence base describing safety hazards in the cardiovascular operating room is weak, but essential to guide future safety improvement efforts. The aim of this paper was to identify and categorise hazards (anything that has the potential to cause a preventable adverse patient safety event) in the cardiovascular operating room. The future focus should be on creating a stronger culture of safety, increasing compliance with evidence-based infection control practices and improving communication and teamwork.

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.