Improving the governance of patient safety in emergency care: a systematic review of interventions

February 24, 2016

Source:  BMJ Open 6/1

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Date of publication:  January 2016

Publication type:  Systematic review

In a nutshell:  The objective of this study was to systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.

The conclusions were that the characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in emergency medical services organisations and emergency departments. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base.

Length of publication:  1 webpage

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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


Six-monthly patient safety incident data published

October 30, 2013

Source:  NHS England

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Date of publication:  September 2013

Publication type:  News item

In a nutshell:  The publication of 6-monthly data on patient safety incidents has been welcomed by NHS England. All incidents in which any patient could have been harmed or has suffered any level of harm, are reported to the National Reporting and Learning System (NRLS) by acute hospitals, mental health services, community trusts, ambulance services and primary care organisations.

Length of Publication:  1 web page


Prevalence, reporting and pressure ulcer management

December 22, 2010

Source: Healthcare Quality Improvement Partnership – HQIP

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Date of publication: 3 October 2010

Publication type: Report

In a nutshell: This item looks at how, through incident report monitoring and clinical audit against NICE guidelines, one Trust successfully dealt with the management of pressure ulcers, realising both improved patient care and quality .

Length of publication: 1 page


After the abolition of the National Patient Safety Agency

December 22, 2010

Source: British Medical Journal

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Date of publication: 3 November 2010

Publication type: Editorial

In a nutshell: Abolishing the NPSA may include the NHS Reporting and Learning system, the national database of reported patient safety incidents. The database highlights areas of concern and provides evidence around the number and severity of incidents on a national scale.

Length of publication: Webpage

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.


Organisation Patient Safety Incident Reports March 2010

June 9, 2010

Source: National Reporting and Learning Service

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Date of publication:  March 2010

Publication type:  Report

In a nutshell:  Access patient safety incident reports for individual NHS organisations in England and Wales.

Length of publication:  1 web page

Achnowledgements:  National Patient Safety Agency