Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients

Source:  Annals of Surgery 261/5 pp. 831-8

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Date of publication: May 2015

Publication type:  Journal article

In a nutshell: This review aims to systematically risk assess and analyse the escalation of care process in surgery to identify problems and provide recommendations for intervention. It discusses Healthcare-Failure-Mode-Effects-Analysis (HFMEA), a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. Failures in the escalation process amenable to intervention were systematically identified in this review. The authors say that the mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

Length of Publication:  8 pages

Airline style patient safety film set to land in hospitals

Source:  Salford Royal NHS Foundation Trust

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Date of publication:  October 2014

Publication type:  News item

In a nutshell: A new ‘airline style’ film to give patients advice on how to stay safe in hospital has been created with the help of staff at Salford Royal. The film has been developed by Haelo in partnership with Guys’ and St Thomas’ Hospitals NHS Foundation Trust. The film aims to reduce avoidable complications such as blood clots, pressure ulcers or falls. Patients will also be provided with an information card with advice on looking after themselves during their hospital stay. The safety advice is being supported by Health Secretary, Jeremy Hunt, and the national Sign up to Safety campaign. The film can be easily incorporated into Trust websites so patients can watch it before they come into hospital. Hospitals with the Hospedia patient media system are also able to have the film uploaded free of charge to show patients once in hospital.

Length of Publication:  1 web page

The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study

Source:  BMC Health Services Research 14 pp. 432

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Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: There is evidence that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to the reasonable adjustments that they need not being implemented. This article aimed to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities. It describes the patient safety issues that patients with intellectual disabilities in NHS acute hospitals encounter and investigates underlying contributory factors. The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents.

Length of Publication:  1 web page

Patient safety incident reporting continues to improve

Source:  NHS England

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Date of publication:  September 2014

Publication type:  News item

In a nutshell: The publication of six-monthly data on patient safety incidents reported to the National Reporting and Learning System (NRLS) between 1 October 2013 and 30 April 2014 shows the NHS is continuing to get better at recognising and reporting patient safety incidents. The increase in the level of reported incidents shows that the NHS is continuing to be more open and transparent about reporting patient safety incidents. Incident reporting is important at a local level because it allows clinicians to learn about why patient safety incidents happen within their own service and organisation, and what they can do to keep their patients safe from avoidable harm.

Length of Publication:  1 web page

Sign up to Safety

Source:  NHS England

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Date of publication:  June 2014

Publication type:  News item

In a nutshell:  A new campaign to make the NHS the safest healthcare system in the world, building on the recommendations of the Berwick Advisory Group, has been launched by the Secretary of State for Health. The campaign sets out a three-year shared objective to save 6,000 lives and to halve avoidable harm as part of NHS England’s aim to ensure patients get harm free care every time, everywhere. The Sign up to Safety campaign is for everyone in the NHS. For more information visit the Sign up to Safety website.

Length of Publication:  1 web page

Health and safety in the NHS

Source:  British Journal of Nursing 23/2 pp112-113

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Date of publication:  January-February 2014

Publication type:  Journal article

In a nutshell:  Each year, accidents at work cost the NHS a large amount of money. The most common cause of claim for compensation faced by the NHS is for accidents that are due to avoidable slips and falls. In the first of a series, this article on health and safety law sets out the duties imposed on NHS organisations and their employees.

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.

Reducing harm to patients

Source:  The Health Foundation

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Date of publication:  March 2014

Publication type:  Report

In a nutshell: This Health Foundation briefing follows a March 2014 speech by the Secretary of State for Health at Virginia Mason Medical Center in Seattle. Jeremy Hunt MP set out a new ambition to reduce avoidable harm to patients in the NHS during his speech. In recent years, the Virginia Mason Centre has had considerable success in delivering safe care and financial sustainability. This briefing outlines the factors that have contributed to their success, and how a similar approach has been used in the UK. It aims to help those working to improve patient safety in the NHS. The Health Foundation set out five questions that organisations should ask themselves to help make the ambition to reduce avoidable harm a reality.

Length of Publication:  1 web page

Five minutes with … a patient safety champion

Source:  The Guardian, Friday 4 October 2013

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Date of publication:  October 2013

Publication type:  News item

In a nutshell:  As a patient safety champion, Colin Hewson, would like to see a more open and transparent culture in the NHS to help reduce avoidable harm. He works with a small team of enthusiastic patient safety champions, who attempt to bring their knowledge of reducing harm in high-risk sectors of industry to the NHS. Colin and the team introduced a programme called TalkSafe, which was selected as a finalist in the 2013 Patient Safety Awards.

Length of Publication:  1 web page

Safe and effective service improvement: delivering the safety

Source: Amnis

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Date of publication: May 2011

Publication type: Guidance

In a nutshell: These guidance notes look at implementing Lean as a method of improving patient safety.  This approach looks at reducing costs, time and supplies.  It can also reduce the number of near misses through events that can result in severe death or harm to a patient.

Length of publication: 27 pages

A wake up call – lessons from the first major improvement programme

Source: The Health Foundation

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Date of publication: 4 February 2011

Publication type: News item

In a nutshell: The Health Foundation looks at their ‘Safer Patient Initiative’,  evaluating the lessons learned from it.  It also looks at the success achieved on ward level, and raising awareness of these issues across the UK.  However, more lessons are to be learned if this is to have an impact at organisation level, and this article highlights some of the ways to achieve this.

Length of publication: 1 webpage