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

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

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

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

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

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

Staff and public urged to help shape new patient safety body

Source:  NHS Networks

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Date of publication:  November 2015

Publication type:  News item

In a nutshell:  NHS staff, patients and members of the public are being urged to have their say on the shape of a new national patient safety organisation.

The health secretary announced in the summer that he would create an independent function to oversee the investigation of patient safety incidents.  An expert advisory group has been established to collect evidence and make recommendations on the roles and responsibilities of the new body, ahead of its formation in April 2016.

An online survey to capture the views of patients and professionals can be found at www.surveymonkey.com/r/ipsis2015

Length of publication:   1 webpage

General practice patient safety reporting form launched

Source:  NHS England

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Date of publication: February 2015

Publication type:  News item

In a nutshell: A new e-form has been launched to enable general practice staff to quickly and easily report patient safety incidents to the National Reporting and Learning System (NRLS). The number of safety incidents reported to the NRLS from primary care remains low, making it difficult to develop appropriate and relevant support and learning resources for practice staff. The new e-form can be completed in a matter of minutes, with many questions requiring quick and simple answers. Practices can choose to include their practice code or can submit a report anonymously. Patient identifiable information is also not required. Upon submission of the incident report there is the option to request a bounce back email with a Significant Event Audit template which can be used for CPD, Appraisal and Revalidation. This can also provide evidence of patient safety activity during CQC inspections.

Length of Publication:  1 web page

Online patient safety education programme for junior doctors: is it worthwhile?

Source:  Irish Journal of Medical Science Epub ahead of print

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Date of publication:  November 2014

Publication type:  Journal article

In a nutshell:  This study looked at online learning about patient safety for junior doctors in Ireland and asked if it is valuable. The participating doctors completed a baseline survey and a follow-up survey. The online initiative resulted in immediate improvements in self-reported knowledge such as knowing when and how to complete incident forms and disclosing errors to patients, and in attitudes towards error reporting. The interactive features were the most positive elements of the programme. The authors conclude that online training about medical errors improved junior doctors self-rated knowledge, attitudes and skills in Ireland.

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

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

An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Source:  Anaesthesia 69/7 pp. 735-45

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Date of publication:  July 2014

Publication type:  Journal article

In a nutshell:  One of the key tools promoted for improving patient safety in healthcare is incident reporting. The authors of this study analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units in the North West of England every year between 2009 and 2012. 452 of the incidents led to harm to patients. The most commonly reported drugs were noradrenaline, heparins, morphine and insulin. The administration of drugs was the stage where incidents were most commonly reported. This was also the stage most likely to harm patients. The authors conclude that quality improvement initiatives could improve medication safety in the units studied.

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 Safe is my Hospital’ site launched

Source:  EHealth Insider

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Date of publication:  June 2014

Publication type:  News item

In a nutshell:   This news reports on a new section on NHS Choices which will include Trust compliance on ward staffing, incident reporting, pressure ulcers, falls and patient safety. The Department of Health has launched the site, which will enable the public to compare hospitals in England based on a number of safety indicators. The launch is part of the ‘Sign up to Safety’ campaign that aims to save up to 6000 lives over the next three years. The trusts will be ranked according to how openly they are reporting and will be rated as ‘good’, ‘acceptable’ or ‘poor’. As part of the campaign, Jeremy Hunt has also launched a new Safety Action for England team, made of senior clinicians, managers and patients.

Length of Publication:  1 web page

Predictors of Patients’ Intentions to Participate in Incident Reporting and Medication Safety

Source:  Journal of Patient Safety 2014 Feb 11. [Epub ahead of print]

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Date of publication:  February 2014

Publication type:  Journal article

In a nutshell:  Researchers examined aspects that may influence a patient’s willingness to report a safety error to a national reporting system and to bring their medicines into hospital to allow checking. Beliefs about control were the strongest predictors of patients’ intentions. Their expectations about what is ‘normal’ behaviour influence the extent to which they may participate in patient safety initiatives. The researchers concluded that initiatives to improve patient involvement in safety should consider the extent to which people feel in control and capable of performing the behaviour.

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

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.

Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.

Source:  Research in Social and Administrative Pharmacy Vol/iss 9/1 pp.80-89

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Date of publication:  January 2013

Publication type:  Journal article

In a nutshell:  In England, hospital pharmacists said that medication errors are common and that they are often not reported. Error reporting forms are thought to be cumbersome and time consuming. It could be useful to simplify reporting forms, ensure staff are praised for reporting and make sure that any issues are addressed quickly so that staff feel that reporting is worthwhile.

Length of Publication:  10 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.